Ventilator alarm failure due to modification of the scavenging system.

FAILURE and misuse of anesthetic administration equipment is a cause of death and brain damage associated with anesthesia. However, failure of anesthesia systems is affected by human error in more than 80% of cases that result in critical events and patient injury. These injuries may be prevented with a better understanding of anesthesia equipment and improved monitoring devices. Recently, the potential for prolonged apnea in two ventilator-dependent patients occurred as a result of ventilator alarm failure caused by misuse of anesthesia equipment, which prompted this report.

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