Initial and final report.Caregiver reports patient saturation from 98% to 57% due to occlusion in humidifier.Caregiver was questioned regarding device and reports that after reviewing the device, the occlusion is most likely due to adding saline in water leading to precipitation which blocked some of the openings in the tubing.Labeling states "use sterile, distilled or tap water".Labeling states to clean every 3 days and to discard/replace humidifier if scaling or deposits hoted.Humidifer was in use for at least 5 days prior to event.User not following cleaning and usage instructions.No serious/long-term injury reported.No other similar events reported.Event root cause determined to be user error.
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