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.
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