The Joint Commission received two reports of medical gas mix-ups
in 2000 that resulted in the death of four patients and injury
to five patients. In the past four years, the Food and Drug
Administration (FDA) has received four reports that resulted in
seven deaths and 15 injuries. In early April 2001, the FDA
issued a Guidance for Hospitals, Nursing Homes, and other Health
Care Facilities--Public Health Alert (1) that focuses on its
reports of medical gas mix-ups, their common causes and the
FDA's recommendations for preventing occurrences. This Alert is
being distributed to help spread the word to health care
organizations about steps that can be taken to prevent deaths
and injuries from compressed gases, which include industrial and
medical grade gases. Medical grade gases are considered
prescription drugs and include oxygen, compressed air, carbon
dioxide, helium, nitrogen and nitrous oxide. These medical gases
are either used in medical treatment and procedures, or to power
medical equipment. Industrial g