[Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check?].

ABSTRACT

We experienced an accident related to insufficient checking of the anesthesia machine. The anesthesiologist could not ventilate manually after starting anesthesia. The cause of this case was a simple mistake of not moving the switch from ventilator to bag, but he thought severe asthma attack had occurred with the patient. About 10 minutes was lost before he recognized the real cause and the patient suffered severe hypoxia. After this event we conducted a survey of "Do you really check the anesthesia machine before anesthesia using J.S.A. checklist?" on our seven anesthesiologists. Leak test was carried out almost perfectly but other test was not. Therefore we put anesthesiologists under an obligation to use the check sheet before anesthesia and file the sheet in the medical record. The safety management of anesthesia is not only to take the safety measures but also to check the actual conditions.