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U.S. Department of Health and Human Services

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FDA Public Health Advisory: Medical Gas Mix-Ups Can Cause Death and Serious Injury

Gases for medical use are prescription drugs that must be carefully regulated and handled.

Adaptors should never be used and fittings never changed on medical gas containers. If a connection doesn't fit, it isn't supposed to fit. Contact the supplier immediately.

Store medical grade products separately from industrial grade products in well-defined areas.

Educate and train personnel who are directly responsible for handling medical gas to:

  • recognize medical gas labels
  • examine all labels carefully before hooking containers to the system.

Skilled and knowledgeable personnel should always check the container and connection prior to introducing gas into the system.

 

Medical Gas Mix-ups Connect button - Won't Connect? Don't Connect

 

Patients have been injured - and some have died - because of medical gas mix-ups. This usually occurs when the wrong gas is forcibly connected to the oxygen supply system. Please promote the importance of properly handling medical gases.

  • Manufacturers who receive reports of death or serious injury associated with the use of medical gases are required by law to report these incidents to the FDA.
  • Hospitals, nursing homes, and other health care facilities should submit reports of such mix-ups (whether or not they resulted in a serious injury) to FDA's voluntary report system, MedWatch:

Phone - (800) FDA-1088
Fax -    (800) FDA-1078

Mail
MedWatch, Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20852-9787

US Food and Drug Administration

For more information, call 1-888-INFO-FDA or go to Compressed Medical Gases page.