PERFUSION REPORTS

REPORT

149

DATE

15/9/2026

TITLE

Oxygen sensor gas leak

DETAILS OF INCIDENT

Blender set to 4LPM to test gas flow during set up for a case. Flow did not feel like 4LPM, attached a flow meter to the end of the gas line and it was reading 2LPM.

DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

Teledyne oxygen analyser. Asset number 5003786.

ACTION TAKEN

Further troubleshooting commenced. Attached flow meter to gas line post isoflurane vaporiser/pre O2 sensor and it was reading 4LPM. Disconnected ends of gas line (in and out) from O2 sensor, cut the ends and reconnected them with tie bands. Tested gas flow again, still flowing between 2-3LPM. Removed O2 sensor and replaced with a new one, gas flow reading 4LPM as expected. O2 sensor sent to clinical engineering.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

This is the 2nd reported leak from an oxygen sensor in our department within the last 4 months.

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