The hospital reported that the vaporizer was mounted on a non-validated drager anesthesia machine.It was further reported that the vaporizer was plugged into a powermate that was plugged into a wall outlet.The outlet in the powermate was reportedly loose (connection was not secure).The hospital stated that, at some point during the case, the tec 6 power cord was accidentally knocked out of the powermate.According to the electronic medical record (emr), the patient did not receive agent for over an hour.Following the case, the patient reported having recall of the procedure.
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The hospital reported that, during the case, the vaporizer was plugged into a ¿power mate¿, which was plugged into the wall outlet.The hospital further reported that the outlet in the ¿power mate¿ the vaporizer was plugged into was loose and the connection was not secure.The tec 6 plus manual instructs the user to connect the power cord from the vaporizer to an approved hospital grade outlet socket.The vaporizer was being used on a nonvalidated drager anesthesia machine.The tec 6 plus manual states "the datex-ohmeda vaporizer should be used in anesthesia systems equipped with a selectatec series manifold only".The vaporizer was sent to ge healthcare for investigation.The unit was tested and found to function within manufacturer¿s specifications.
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