M and M of Gas Delivery Equipment (closed claims project)
Most common outcomes = death (47%) and brain damage (29%) related to gas delivery equipment
Closed Claims related to “less than appropriate care”
includes inadequate checking of anesthesia equipment and can lead to HIGH monetary malpractice awards
Prevention and Early Detection of Machine Issues
- key in preventing pt injury
- check must be done prior to use
- back up manual ventilation and oxygen source must be present
- if vaporizers fail, use TIVA
AANA Core Values
– Patient safety
– Care for the whole patient, from a nursing perspective
– Professional excellence and personal well-being
– Healthcare policy and collaboration
– Integrity and quality in all professional and clinical settings
AANA Motto
safe and effective anesthesia care
Standard VIII
- Adhere to appropriate safety precautions, as established within the institution, to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Document on the patient’s medical record that the anesthesia machine and equipment were checked.
- Prior to use, the CRNA shall inspect the anesthesia machine and monitors according to established guidelines. The CRNA shall check the readiness, availability, cleanliness & working condition of all equipment to be utilized in the administration of anesthesia care. Ensure disconnect alarm working with mechanical ventilator. Monitor FiO2 with appropriate alarm on
6th Vital Sign
- checking your machine should be thought of no differently than checking pts pre-op vitals and NPO status
Pre-Anesthesia Machine Check History
- 1984-1988: FDA conducted an internal study of death reports in the FDA Medical Device Reporting (MDR) database.
- 19% of the deaths may have been avoided by a proper pre-anesthesia machine checkout.
- 1987: FDA issued “Anesthesia Apparatus Checkout Recommendations”.
– 24 steps
• Research showed that these guidelines were used inconsistently and the success rates in finding faults in the anesthesia machine were poor.
1993: FDA reduced steps to 14, but still were not readily used and M and M continued to be reported due to machine malfunction until 2008
2008
- APSF published new guidelines
- recognized old guidelines were not well understod and not applicable to newer anesthesia machines
- guidelines were to serve as a starting point for individual departments to develop pre-anesthesia checkout procedures tailored to the equipment and resources avaiable at individual institutions
UIASC Checklist Philosophy (From APSF Guidelines)
• To avoid patient harm through execution of procedures designed to assure the proper function and presence of critical anesthesia requirements including:
– Reliable delivery of oxygen at any appropriate concentration up to 100%.
– Reliable means of positive pressure ventilation.
– Backup ventilation equipment available and functioning.
– Controlled release of positive pressure in the breathing circuit.
– Anesthesia vapor delivery (if intended as part of the anesthetic plan).
– Adequate suction.
– Means to conform to standards for patient monitoring.
– Means to perform adult and pediatric Advanced Cardiac Life Support (ACLS) including the presence of emergency drugs and immediate availability of defibrillation.
2008 APSF Guidelines and Design Checklist
• Delineated what tasks could be done by anesthesia technician and those that had to be done by the anesthesia provider and those that could be double checked.
– YOU ARE ULTIMATELY RESPONSIBLE!!!
Tasks to be Completed Daily, or After a Machine is Moved or Vaporizers are Changed (15 steps)
To Be Completed Prior to Each Procedure (Subset of items in the daily checklist to be completed between cases)
