The device was subject to a full check in follow-up of the event; proper function could be verified.Especially the auxiliary o2 flowmeter was checked, the valve was closing correctly and there was no leakage present.The user facility was not disclosing information whether or not, there was an oxygen flow adjusted at the time the event occurred.It can be considered basic knowledge of trained users that an enriched level of oxygen in a certain environment increases the risk of ignition and fire.The ifu of the auxiliary o2 flowmeter contains an explicit warning that - before cauterizing, the flow meter has to be closed, the mask removed and a few moments have to be passed by to ensure that any oxygen accumulation has dissipated.It seems that the staff did not follow these warnings.Dräger concludes that no malfunction of the workstation or flowmeter has occurred which may have caused or contributed to the event.
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It was reported that near the end of a case, the anesthesiologist noticed flames coming from the patient's mask.As a result, the patient suffered burns to his/her mouth, hair, and lips.The hospital was contacted and it was determined the patient was not connected to the fabius gs ventilator or under anesthesia, but only the auxiliary o2.Draeger was informed that they were cauterizing during the procedure when the ignition occurred.
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