The mystery of the broken blood gas analyzer

ON the subject of Advent and Christmas, Health and Medical research literature do not bring good tidings but bad news. This bad news can range from children choking on Christmas tree decorations to major burn injuries, such as the one reported in the “Annals of Burns and Fire Disasters” in 2015.

Recently, I found another bad news in Christmas research literature. This was published back in 2012 and involved an accident in a clinical laboratory not in the Philippines but in a hospital in Northern Ireland. It was reported in the journal “Anesthesia,” Volume 67 (Issue 12). One of the researchers, J. Lavery, was the senior clinical technologist in the hospital’s clinical laboratory and an eyewitness of what happened. The other authors are C. Martin from the Anesthetics and C. Clarke, consultant in Anesthetics and Intensive Care Medicine in the hospital.

(By the way, the article is not a research report but an essay reporting the incident. It is still a “report,” isn’t it?)

Well, the accident occurred, perhaps in part, because of the wonders of today’s diagnostic technology. The machine involved was the ABL810 blood gas analyzer used for blood chemical analysis. Like most machines today, it is operated with a touch screen, programmed to record single-touch “commands” (valid touch) and interpret as “erroneous” (invalid touch) all multiple-touch (i.e. touching the same keys many times) commands. This is supported by infrared touch screen technology.

Now, the laboratory management loves the Christmas season. So, they decorated the outer portion of the analyzer screen with a colorful, but fake, tinsel décor. One day, the clinical technicians discovered that the machine broke down due to multiple errors. They investigated the mystery only to find out that the culprit was the tinsel décor. It turned out that the tinsel décor had “reached out” to the analyzer screen and kept on touching it repeatedly. The machine had to report multiple erroneous entries and broke down.

Now, the authors suggested that “multiple touching is a particular hazard” during the Advent Season, urging their “colleagues to exercise caution.”

For that, I have no theological explanation.

Merry Christmas!


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