WRONG CONNECTION OF A MEDICAL AIR FLEXIBL E HOSE TO A NITROUS-OXIDE OUTLET MADE POSSIBLE BY A DEFECTIVE FAIL-SAFE DEVICE

When plugging the O-2, N2O and air hoses into the corresponding wall s ockets, the air hose was wrongly inserted into the N2O wall outlet. Th is was made possible because of faulty retaining clasps of the male co upler of the air probe. French ''fail-safe'' connections consist of a two-clasp male coupler for air, three clasps for O-2 and four clasps f or N2O hoses. Additionally the clasps of the air probe are broader the n those of the N2O probe. However, the latter difference was lost due to wear. The incident was recognized without delay as the N2O hose cou ld not be inserted into the air outlet. However, it could have remaine d unnoticed had there bean two N2O wall outlets and could have resulte d in severe adverse effects.