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MDA/2007/090 - Anaesthetic Gas Scavenging System (AGSS) receiver, manufactured by Draeger Medical

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Document details:

Type: Medical Device Alert
Series No: MDA/2007/090
Audience: Healthcare professionals
Published:
Format: Electronic and paper
Size: A4
Pages: 5
Price: Free
ISBN/ISSN:
Author:
Copyright: Crown
   

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Page 1

Issued: 04 December 2007 at 11:00
Ref: MDA/2007/090

 

 
Immediate action
Tick mark
Action
 
Update
 
Information request


Device:
Anaesthetic Gas Scavenging System (AGSS) receiver, manufactured by Draeger Medical.

>Page 2

Problem:
There have been reports of anaesthetic scavenging hoses being misconnected to the blanked-off port of the Draeger AGSS receiver (see appendix).   This prevents gases from leaving the anaesthetic breathing system, creating excessive airway pressures, which if undetected could result in serious lung injury.

>Page 2

Action by:
Anaesthetists, operating department practitioners, anaesthetic nurses and servicing engineers.		  

Action:

  • Ensure that all anaesthetic staff using this device are aware of this potential misconnection.
  • AGSS connections must be included in the pre-use checks of the anaesthetic breathing system to ensure the scavenging hose is connected to the open port of the AGSS receiver.
 

Distributed to:

NHS trusts in England - Chief Executives*
Healthcare Commission (CHAI) - Headquarters

* via CE Bulletin

>Page 2

Contacts:
Details of manufacturer contacts and MHRA contacts for technical and clinical aspects.
Change of address or removal from address list for Healthcare Commission.

>Pages 2-3

Appendix:
Diagrams showing how the problem could occur (in pdf only).		  

>Pages 4-5



 

Action deadlines for the Safety Alert Broadcast System (SABS)
Deadline (action underway): 17 December 2007
Deadline (action complete): 02 January 2008

Page last modified: 04 December 2007