Preventing Medical Gas Mix-ups

Save lives with four simple steps

Since 2000, there have been no fatal incidents involving medical gas mix-ups resulting from incorrectly connected cryogenic medical gas containers. However, in the previous 17 years, 12 people died and many more were injured as a result of medical gas mix-ups.

This result is due, in large part, to the highly effective engineering controls our industry and the FDA established to prevent any future fatalities from medical gas mix-ups. These controls included requiring tamper-proof connections on the outlet valves of medical portable cryogenic containers and the use of a 360-degree wraparound identification label.

It is very likely that some of your employees do not remember the events of the 1980s and 1990s that resulted in the tragic deaths of patients who relied on a safe medical gas. It is also possible that the effective engineering controls that were implemented are not well understood by your present operators and drivers. It is also possible that not all your liquid containers have this tamper-proof control.

Now is the time to refresh our understanding of the critical preventive measures that have been shown to save lives by preventing medical gas mix-ups … before another incident.

CGA SB-26, Cylinder Connections on Portable Liquid Cryogenic Containers, is a short, two-page, Safety Bulletin that clearly explains the engineering controls and the history of their development and that demonstrates the ability of our medical gas industry to regulate itself and save lives.

Four Critical Action Steps

  1. Get SB-26. Go to cganet.com and download the latest version of CGA SB-26. This publication, and all CGA publications, are free to GAWDA members who participate in the GAWDA/CGA Safety Program. Otherwise the cost is only $5.
  2. Make sure all of your liquid containers are compliant with the simple requirements in SB-26.
  3. Train Pumpers — Be certain that your cryogenic container filling personnel and supervisors understand the critical elements of CGA SB-26 that apply to them:
    1. Medical portable cryogenic container outlet valves must be fitted with tamper-proof connections
    2. Industrial portable cryogenic container outlet valves must be fitted with tamper-evident or tamper-proof connections. This includes (N2O,, CO2, Ar, N2, O2).
    3. Cryogenic containers should be labeled according to CGA C-7, Guide to Classification and Labeling of Compressed Gases, including the 360-degree wraparound label.
  4. Train Drivers — Be sure your drivers understand the critical elements of CGA SB-26 that apply to them:
    1. How to recognize medical versus industrial containers. The label is the primary identification for medical gases. The 360-degree wraparound tape and other measures are secondary identification techniques.
    2. Never use an adapter to connect a cylinder/container to a customer system.
    3. Never change an outlet connection.

If the connections between the container and the customer’s system do not fit — do not make the connection. “Won’t Connect? — Don’t Connect!”

“Won’t Connect? — Don’t Connect!”

These simple steps can save lives by preventing another tragic medical gas mix-up.
Contact tom@asteriskllc.com for:

  1. A white paper with the details of the incidents from the 1980s and 1990s
  2. A sample Operator Training Program to prevent medical gas mix-ups (CGA SB-26 principles using PowerPoint presentation, quiz, answer key, documentation and video)
  3. A sample Driver Training Program to prevent medical gas mix-ups (CGA SB-26 principles using PowerPoint presentation, quiz, answer key, documentation and video)
  4. Sample photos of conforming and non-conforming cryogenic container connections.
Meet the Author
GAWDA’s FDA & Medical Gases Consultant Thomas L. Badstubner is president of AsteRisk LLC in Lewisville, Texas. Members can reach him at 508-883-0927 and tom@asteriskllc.com.