Compliance with current anaesthetic equipment safety guidelines in the light of a cluster of avoidable anaesthetic deaths

Over the last 2 years a cluster of serious untoward incidents have been reported to the medical regulators in Germany, France and other countries. These severe complications after the induction of general anaesthesia were caused by wrongly assembled breathing circuits. In addition, cases of blocked tubes with fatalities have been reported in the UK and corresponding recommendations published. In response, the European Patient Safety Foundation, European Society of Anaesthesiology, German Society of Anaesthesiology and Intensive Care Medicine and the Swiss Anaesthesia Patient Safety Foundation have now launched safety alerts on wrong tube connections to the anaesthesia workstation, highlighting the importance of anaesthetic equipment checklists 1. The importance of a pre-use check of anaesthetic equipment is recognised worldwide and the check has been included in the World Health Organization's Surgical Safety Checklist 2 and the Association of Anaesthetists equipment checklist 3. Although anaesthetic equipment checklists were introduced many years ago, poor adherence has been reported 4, 5. We audited adherence to current Association of Anaesthetists guidelines. Approval was given by the clinical audit departments of the participating hospitals, all grades of anaesthetists were approached and consent was taken after a detailed explanation of the study objective was given. All members of staff participated voluntarily, appropriately protected from coercion. The data obtained were anonymised and kept strictly confidential. Twenty-nine items of the Association of Anaesthetists anaesthetic equipment checklist were compiled to form a questionnaire and handed to anaesthetists at three major London teaching hospitals. We obtained anonymised responses from a total of 120 anaesthetists. Not a single anaesthetist reported full adherence to the current national guideline. Although nearly half of the respondents acknowledged that the two-bag test is the most useful test to confirm patency and integrity of the breathing system, only a quarter reported routine use of this test. Approximately 20% of anaesthetists did not know, or assumed wrongly, that the internal machine check would indicate that the breathing system was patent and correctly assembled. Another important finding was that only one-fifth of respondents checked the availability of difficult airway equipment, including front-of-neck access kit, before inducing general anaesthesia. We found that the two main reasons for poor adherence were time pressure and being unaware that the final responsibility remains with the anaesthetist, even if the assistant fails to do the safety check or fails to spot a fault. Furthermore, many anaesthetists were unaware regarding the limitations of an automated internal machine check. In the light of the most recent series of serious untoward incidents our results are concerning. Root cause analyses of reported hypoxic incidents found that wrongly assembled breathing systems or blocked parts of the breathing system were a common factor. It appears that these cases could have been avoided if the breathing circuit was checked using the ‘two-bag test’. This test has been incorporated into the 2012 Association of Anaesthetists guidelines but seems to have not yet become part of our daily safety routine. Following the cluster of severe untoward incidents, Prien et al. recently published an ‘open mind article’, promoting the ‘PaF’ test and discussing future technical solutions in order to reduce the risk of breathing circuit assembly problems 6. Until we find technical solutions to this problem, the results of our audit highlight the need for improved awareness, training, communication and documentation of anaesthetic equipment checks.