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Failure of a “foolproof” pin-index medical pipeline system

BACKGROUND: The pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be “foolproof” and is widely used in Japan to avoid medical gas misconnections. CASE PRESENTATION: The wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, C...

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Autores principales: Ishimura, Tatsuhiro, Ikuta, Yoshihiro, Yamamoto, Tatsuo
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Springer Berlin Heidelberg 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818779/
https://www.ncbi.nlm.nih.gov/pubmed/29497675
http://dx.doi.org/10.1186/s40981-016-0044-7
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author Ishimura, Tatsuhiro
Ikuta, Yoshihiro
Yamamoto, Tatsuo
author_facet Ishimura, Tatsuhiro
Ikuta, Yoshihiro
Yamamoto, Tatsuo
author_sort Ishimura, Tatsuhiro
collection PubMed
description BACKGROUND: The pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be “foolproof” and is widely used in Japan to avoid medical gas misconnections. CASE PRESENTATION: The wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, Co., Ltd., Tokyo, Japan) contains multiple sockets, which connect to hoses with gas-specific pins. Each socket is covered with a gas-specific plastic pin guide, which is considered to make the system foolproof; i.e., to prevent misconnections. However, while checking an anesthesia machine in accordance with the guidelines developed by the Japanese Society of Anesthesiologists, an anesthesiologist found that one of the gas-specific plastic pin guides covering the wall-mounted gas outlets had disappeared; and hence, the gas outlet system was no longer foolproof. A subsequent verification test performed by engineers of the system’s manufacturer revealed that the plastic pin guides could be dislodged by applying 29.4 N of vertical force. CONCLUSIONS: It is important to check that gas outlet systems are functioning in a gas-specific manner when they are used for clinical purposes.
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spelling pubmed-58187792018-02-27 Failure of a “foolproof” pin-index medical pipeline system Ishimura, Tatsuhiro Ikuta, Yoshihiro Yamamoto, Tatsuo JA Clin Rep Case Report BACKGROUND: The pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be “foolproof” and is widely used in Japan to avoid medical gas misconnections. CASE PRESENTATION: The wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, Co., Ltd., Tokyo, Japan) contains multiple sockets, which connect to hoses with gas-specific pins. Each socket is covered with a gas-specific plastic pin guide, which is considered to make the system foolproof; i.e., to prevent misconnections. However, while checking an anesthesia machine in accordance with the guidelines developed by the Japanese Society of Anesthesiologists, an anesthesiologist found that one of the gas-specific plastic pin guides covering the wall-mounted gas outlets had disappeared; and hence, the gas outlet system was no longer foolproof. A subsequent verification test performed by engineers of the system’s manufacturer revealed that the plastic pin guides could be dislodged by applying 29.4 N of vertical force. CONCLUSIONS: It is important to check that gas outlet systems are functioning in a gas-specific manner when they are used for clinical purposes. Springer Berlin Heidelberg 2016-08-08 2016 /pmc/articles/PMC5818779/ /pubmed/29497675 http://dx.doi.org/10.1186/s40981-016-0044-7 Text en © The Author(s) 2016 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
spellingShingle Case Report
Ishimura, Tatsuhiro
Ikuta, Yoshihiro
Yamamoto, Tatsuo
Failure of a “foolproof” pin-index medical pipeline system
title Failure of a “foolproof” pin-index medical pipeline system
title_full Failure of a “foolproof” pin-index medical pipeline system
title_fullStr Failure of a “foolproof” pin-index medical pipeline system
title_full_unstemmed Failure of a “foolproof” pin-index medical pipeline system
title_short Failure of a “foolproof” pin-index medical pipeline system
title_sort failure of a “foolproof” pin-index medical pipeline system
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818779/
https://www.ncbi.nlm.nih.gov/pubmed/29497675
http://dx.doi.org/10.1186/s40981-016-0044-7
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