Avoid medical-gas mix-ups.

The Food and Drug Administration (FDA) has published Guidance for Hospitals, Nursing Homes and Other Health Care Facilities to alert health care personnel to the hazards of medical-gas mix-ups. This advisory is in response to several reports of deaths and injuries to patients who were given the wrong gas. One incident involved four Ohio nursing home residents who died when nitrogen was substituted for oxygen. (See "Companies charged in resident deaths," April 2001 GLTC, page 7.) In other cases, hospital patients died or suffered severe injuries when they received nitrogen, argon, or carbon dioxide.

Many medical gases are incorrectly or poorly labeled, and the wrong canisters may be delivered to health care facilities. In several incidents cited by die FDA, maintenance workers were apparently unaware that connectors for oxygen canisters are designed to fit only onto oxygen systems. After they tried unsuccessfully to install canisters containing deadly gases, the workers borrowed fittings from empty oxygen tanks. The FDA recommends storing medical gases separately and instructing those who handle the canisters never to alter the fittings. Download the guide at [less than]httpi://www.fda.gov/cder/guidance/4341fnl.pdf[greater than].