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Posted on 10 Oct 2018
Incident response/review
11 October 2018

Immediate actions for health services

Following a recent near miss involving a faulty medical air tee adaptor, please:

  • audit your current stock to identify any other aberrant adaptors
  • inspect all new adaptors prior to use, and remove/quarantine aberrant adaptors
  • remind staff of the importance of checking that hoses are connected to the correct  wall supply.

Background 

Safer Care Victoria was recently notified of a clinical incident during which an aberrant three-way medical gas tee adaptor enabled both medical air (black) and oxygen (white) cabling to be connected to the same outlet.

This resulted in the brief delivery of medical air instead of oxygen to an infant. An unusual noise from the wall oxygen supply alerted staff to the problem and a serious adverse event was averted. 

Identifying an aberrant adaptor

Medical gas tee adaptors are designed to provide a second connection to a medical gas terminal outlet or regulator. The plastic hand-wheel on each adaptor is colour-coded (black for medical air and white for oxygen). The circular metal connector sleeves are made with specific diameters to ensure the adaptor is connected to the correct gas supply.

The medical air tee adaptor in question had been incorrectly manufactured. It has a black hand-wheel, but two different metal connector sleeves: one for oxygen and one for medical air. This allowed the inadvertent connection of both oxygen and a medical air hose to the same medical air outlet, as shown below:

An image of the aberrant adaptor

The manufacturer has been notified and has taken steps to modify quality control procedures. The Therapeutic Goods Administration has also been notified of the incident. We will update you if further advice is issued. 

More information

Sam Green
(03) 9096 2731
sam.green@safercare.vic.gov.au

Page last updated: 10 Oct 2018