The event involves an anesthesia machine, the ge aisys cs2, which was introduced to our hospital mid (b)(6) 2016.The flowmeter digital field/dial is adjacent to the vaporizer digital field/dial.When using sevoflurane, both of these fields are yellow.In addition, typical air/o2/n2o flows are around "2" and the typical setting for sevoflurane is also around "2." the result is having two digital fields that are both yellow with similar numbers.We had an event where an anesthetist was intending to increase the vaporizer flow, but unintentionally increased the oxygen flow instead.This resulted in a period of unrecognized under delivery of volatile anesthetic.Subsequently, the patient experiences awareness.In addition, it is required to confirm the previous vaporizer setting after replacing a cassette intraoperatively.After 30 seconds, if not confirmed, there is a faint buzz - too soft to hear, and the vaporizer is automatically turned off.We have had incidences again where there was a period of time when we were unintentionally under delivering volatile anesthetic - potentially resulting in awareness.We feel that the need to confirm the setting is redundant and dangerous intraoperatively (it should automatically go back to last setting) and the alarm to indicate the vaporizer being turned off is too subtle.
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