Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen.

The alert asks providers to purchase alternative devices that do not require medical air to be delivered via an air flowmeter. Following this, all medical air flowmeters except those tethered to equipment for niche use should be discarded, and all medical air outlets no longer required should be reversibly capped off.