Eventful anaesthesia: can we prevent it?

Area of Science:

• Anesthesiology
• Patient Safety
• Medical Device Engineering

Background:

• Pre-anesthesia machine and breathing system checks are standard safety protocols.
• Operating room incidents can occur due to factors beyond the anesthesiologist's control.
• These incidents may jeopardize patient safety despite routine checks.

Observation:

• Delayed occlusion of spiral reinforced endotracheal tubes during prone anesthesia.
• Faulty dual control knobs on anesthesia machines causing inadequate ventilation.
• These specific events could not be prevented by standard pre-anesthesia equipment checks.

Findings:

• Standard pre-anesthesia checks are insufficient to prevent all intraoperative adverse events.
• Factors like endotracheal tube occlusion and faulty machine controls pose risks.
• The occurrence of these events is independent of routine pre-operative equipment verification.

Implications:

• Anesthesiologists must be prepared for unforeseen equipment failures or complications.
• Implementing backup strategies or 'deputy objects' is crucial for managing unexpected events.
• Ensuring patient safety requires a multi-faceted approach beyond initial equipment verification.