Misconnection of piping during preparation for intermittent hemodialysis in the intensive care unit

Examples of chlorine gas generation and countermeasures

Abstract

A personal reverse osmosis machine and a personal dialysis machine are used for intermittent hemodialysis in the intensive care unit. At our hospital, water spouted from a personal dialysis machine due to a connection error in the pipes during preparation for treatment, and an accident occurred in which chlorine gas was generated due to a mixture of chlorine-based and acidic cleaning agents. After that, countermeasures were taken to minimize damage and prevent the subsequent generation of chlorine gas. After this experience, we became keenly aware that there are many causes of major accidents hidden behind treatment procedures. Therefore, when deciding and reviewing operations, it is necessary to consider all possibilities and implement multiple safety measures.