Nonetheless, he removed an oxygen fitting from an empty vessel, installed it on the carbon dioxide vessel, and attached it to the oxygen supply system. Two patients were injured critically, and four patients experienced varying stages of respiratory distress. Prior to installing the cryogenic vessel to the oxygen supply system, the person making the connection did not examine the drug label applied to the cryogenic vessel to ensure that the product was medical oxygen. Although recommended by the Compressed Gas Association, many of the large cryogenic vessels used to contain medical gases do not have permanently brazed, or welded, connections or fittings that cannot be removed. Separate storage areas often are not provided either in the delivering vehicle or at the receiving facility to sufficiently separate medical grade products from industrial grade products.
Patients continue to suffer injury or death.
It is important that all employees handling a medical gas be alerted to and reminded of the possible hazards associated with using medical gas. If your facility receives medical gas deliveries, you should store medical grade products separately from industrial grade products. The storage area for medical grade products should be well defined with one area for receiving full cryogenic vessels and another area for storing empty vessels. All personnel who will be handling medical gases should be trained to recognize the various medical gas labels. Personnel should be trained to examine all labels carefully.