Moisture ingress in a hospital medical air system secondary to dryer failure leading to service disruption

Summary

Medical air is essential for the safe delivery of anaesthesia, critical care and emergency care. We report a hospital‐wide medical air contamination event caused by failure of ageing desiccant dryers. Water was detected in the intensive care unit medical air outlets, before moisture contamination was confirmed within the medical air pipeline system and operating theatre pendants. This resulted in shutdown of the central medical air plant, suspension of non‐urgent surgery, surgical bypass and a 5‐day disruption to normal hospital services. The principal clinical challenges were the loss of reliable medical air supplied via the pipeline system, potential moisture exposure of anaesthetic ventilators and other equipment, limited capacity to provide ventilatory support and initial inability to use available medical air cylinders with anaesthetic workstations because of pressure regulator incompatibility. Management required immediate cessation of use of the medical air pipeline system, use of alternative medical air supplies, liaison with the anaesthetic machine manufacturer, installation of a temporary dehydrator, moisture removal and compliance testing. This case highlights that visible water at a medical gas outlet is a serious infrastructure failure requiring urgent escalation and multidisciplinary management. The primary educational message is that medical air‐drying systems require proactive maintenance, lifecycle replacement and continuous dew‐point monitoring linked to hospital alarm systems. Secondary lessons include the importance of tested backup medical air plans, equipment‐compatible regulators and staff education to recognise moisture ingress as a high‐risk patient safety event.