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The recent death of one neonate and injury to another due to resuscitation with nitrous oxide and not oxygen highlights the continuing risk associated with the delivery of piped nitrous oxide into hospitals. The cause of this incident was not unique, with many identical deaths and injuries occurring frequently around the world over several decades. While standards and design focus are often directed at the equipment used by clinicians, attention also needs to be directed at developing safety mechanisms throughout an entire gas delivery process to prevent ongoing tragedies associated with gas-delivery errors.