Abstract
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.