[2959415]
Upon inspecting the transport incubator for the neonatal transportation aircraft, our clinical engineer discovered a factory defect on the dual oxygen/air hose. The oxygen (o2) and air connections were reversed on the o2/air hose where it connects to the ventilator. The hose was in use in the fall of 2012. Due to the design of the ventilator on this transport incubator, there were no o2 sensors that would have alerted the flight nurse that the o2 and air sources were inverted. O2 percentage is determined via a mechanical blender. With the defective hose, o2 concentrations delivered to the patient are not accurate compared to the blender settings. This defective hose is only in use when the incubator is hooked into a hospital's o2/air system via wall outlets, or when hooked into a helicopter or airplane via wall outlets. It is not used during transport when using the tanks on the stretcher/incubator. During the time period that the hose was in service there were 9 confirmed patients that were transported in this incubator plus two additional that may have been transported in this incubator. An examination by our flight nurse team and risk management showed no adverse effect on the patients transported during this time. ======================manufacturer response (per site reporter). ======================the manufacture is conducting their own internal investigation to determine possible root cause. In addition they are proactively notifying other customers that may have possibly been affected.
Patient Sequence No: 1, Text Type: D, B5