Drop in oxygen supply pressures: Misleading gas cylinder color coding to be blamed for nearing a mishap?

We would like to report a case of an erroneous carbon-dioxide cylinder color coding which was mistaken as oxygen cylinder. However with prompt recognition and immediate intervention serious patient morbidity and mortality was averted. There are several international safety mechanisms for medical gas cylinders like labeling, pin index safety system, pressure relief valve and color coding [1, 2]. Inaccurate cylinder color coding and ambiguous labeling of oxygen cylinders can cause catastrophic complications [3, 4].
Source: Journal of Clinical Anesthesia - Category: Anesthesiology Authors: Tags: Correspondence Source Type: research