The device log indicates that the last system test was performed in the afternoon of the day before the reported date of event and was passed w/o deviations.It can furthermore be revealed that, 16 minutes before the procedure in question was started, the device which was in standby mode alarmed for central o2 supply low indicating a disconnection from wall supply.The user then started a procedure in manual ventilation.The workstation almost immediately warned the user that no oxygen is being delivered.The device also alarmed for fio2 low since the measured concentration was between 19 and 25 vol%.In the following there were multiple instances logged where the user acknowledged the posted alarms with the 2-minute-silence button.Approx.Half an hour into the procedure the no o2 delivery alarm was removed, indicating the o2 central supply was available again.The measured fio2 remained low around 20vol% confirming that the sample line was disconnected as reported.Ten minutes later the fio2 suddenly increased to 94vol% - the sample line obviously was reconnected to the circuit at this point in time.There were no indications for the potential presence of a device malfunction found.Dräger finally concludes that the event was related to an improper connection of the workstation to the central gas supply.The device posted the corresponding alarms but the user obviously did not respond to them in an appropriate time.All alarms, potential causes & triggering conditions as well as dedicated remedies are described in the instructions for use.
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