The reported event was caused by use error.The clinician did not confirm the agent setting after the vaporizer cassette was reinstalled in the machine after filling.Patient information could not be obtained after multiple attempts.Attempts were made as follows: (b)(6) 2016 via email , (b)(6) 2016 via phone, and (b)(6) via email.User filed medwatch (b)(4).The reported event was caused by use error.The clinician did not confirm the agent setting after the vaporizer cassette was reinstalled in the machine after filling.Patient information could not be obtained after multiple attempts.Attempts were made as follows: (b)(6) 2016 via email , (b)(6) 2016 via phone, and (b)(6) via email.(b)(4).
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Per the user filed medwatch report: "the vaporizer for the anesthesia machine was switched out during surgery.The alarm on the machine and the vaporizer shut off automatically after a short period of time.The process is reliant on human factors, i.E.The anesthesiologist to manually acknowledge and activate the vaporizer.Due to a distraction, anesthesia did not notice the vaporizer had shut off and there was no additional warning from the machine.Patient was not getting the agent necessary to maintain anesthesia and woke during the surgery." upon follow-up with the facility, it was reported that the patient moved and broke some stitches that had to be re-sutured.The facility further reported the patient incurred no injury and experienced no recall of the surgical event.
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