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U.S. Department of Health and Human Services

Safety

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Medical Gas Misconections -- Public Health Advisory

Audience: Hospital Administrators, Risk Managers, Respiratory Specialists

The FDA Center for Devices and Radiological Health (CDRH) issued a Public Health Advisory alerting healthcare professionals to the potential for patient injury when cryogenic vessels containing medical gas are misconnected to oxygen delivery systems. Misconnections cause patients who should receive medical oxygen to receive another gas, such as nitrogen, instead. Over the past four years, FDA has received reports of seven deaths and fifteen injuries associated with medical gas misconnections that occurred in acute care and nursing home settings.

[July 20, 2001 - Public Health Advisory - FDA]