The elbow on the anesthesia circuit no longer has a luer lock cap, but rather a luer-slip cap, on one of the 2 sites on the circuit to connect the gas sampling line (it used to until about 1.5 to 2 years ago).When the patient was masked, the cap "popped open".Due to quick action by the anesthesia staff, no harm was caused.However, this can lead to failure to administer oxygen to a patient and loss of closure of the anesthesia circuit.When i spoke to the manufacturer's rep about this in the past, thinking that this might have been a change due to covid related supply chain issues, i was told it was not.It was a conscious decision on the manufacturer's part, and would remain in place.This is not an isolated incident; it has happened to many practioners on multiple occasions.Fda safety report id# (b)(4).
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