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Overfilling of vaporisers

2002· letter· en· W2142813664 on OpenAlexaboutno aff
Dee Daniels

Bibliographic record

VenueAnaesthesia · 2002
Typeletter
Languageen
FieldMedicine
TopicHealthcare Technology and Patient Monitoring
Canadian institutionsnot available
Fundersnot available
KeywordsMedicineALARMEvent (particle physics)EveningBottleAnesthesiaMedical emergencyMechanical engineeringElectrical engineering

Abstract

fetched live from OpenAlex

After reading recent correspondence regarding a failure of an Ohmeda Tec 5 generation vaporiser (Fernando & Peck. Anaesthesia 2001; 56 :1009–10), I was left with the impression that they described a relatively freak event which was unlikely to be repeated. However, a recent event in our hospital revealed it was relatively easy to overfill this generation of vaporisers without any tilting at all. In fact, several of our vaporisers were overfilled on the same evening. This overfilling may be achieved simply by loosening the filler from the bottle and filling with the vaporiser turned on, manoeuvres that have been used to speed the filling process. Despite our staff being familiar with the current recommendations of the AAGBI [] regarding checking anaesthetic equipment, the overfilling was only noticed when an oversupply of vapour (6.5% when dialled to 1.5%) triggered an alarm on the anaesthetic agent monitor. Fortunately, this incident had no adverse effect on our patient. However, if the faulty vaporiser had been in one of our anaesthetic induction rooms without volatile agent monitoring, and the patient had been less fit, this may not have been the case. This event highlighted the fact that no‐one in our department was aware that these later generation vaporisers could be overfilled, with some convinced by their previous experience that it was impossible. We believe it likely that a similar belief is common around the country. This lack of awareness had contributed to a less diligent checking of the vaporisers and reduced emphasis on training those who filled them. A similar problem with overfilling has been described with older models and led to a Safety Action Bulletin from the Department of Health in 1992 []. There were also interesting discussions in the Canadian press around the same time []. Our incident has taught us an old lesson.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

How this classification was reachedexpand

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.000
metaresearch head score (Gemma)0.000
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesnone
Consensus categoriesnone
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Not applicable · Consensus signal: Not applicable
GenreCandidate signal: Commentary · Consensus signal: Commentary
Teacher disagreement score0.190
Threshold uncertainty score0.923

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0000.000
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0000.000
Bibliometrics0.0000.000
Science and technology studies0.0000.000
Scholarly communication0.0000.000
Open science0.0000.000
Research integrity0.0010.002
Insufficient payload (model declined to judge)0.0000.000

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.050
GPT teacher head0.284
Teacher spread0.233 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it

Classification

machine, unvalidated

Machine predicted; a candidate call from one teacher head, not a consensus.

The models applied no category: nothing in the taxonomy fit this work.
Study designNot applicable
Domainnot available
GenreCommentary

How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".

Quick stats

Citations2
Published2002
Admission routes1
Has abstractyes

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