During an operation an unconscious, anesthetized patient required the administration of air. The anesthesiologist turned on the air from the wall supply and the “quick connect” coupling of the air machine to the wall air supply became disconnected under the pressure of the air. If the coupling had been a screw-type connector instead of a “quick connect” snap coupler, the incident would not have occurred. The patient died from brain damage caused by lack of oxygen during the surgery.

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