[Failure to perform auto-test of anaesthesia machine at the opening of the operating room].
BACKGROUND
controls performed at the opening of the operating room include the anesthesia machine auto-test. Omitting the preoperative checklist is unsafe for the patient and increases the risk of possible breakdowns. The purpose of this study was to evaluate the incidence and the situations in which the auto-test of the machine was not performed at the opening of the operative room.


METHODS
from a database including 55 195 cases between 1st January 2002 and 31st July 2009, a query identified cases in which the auto-test of the anaesthesia machine was omitted and the cases in which anaesthesia was made in spite of the failure of this test. Clinical circumstances were analyzed and anaesthetist and/or nurse anaesthetist were identified from the computerized anaesthesia record.


RESULTS
one hundred and ninety cases (1.24%) were identified. Seventy-three percent of the omissions of the auto-test occurred while on duty whereas 85% of the failures of the auto-test took place at the beginning of the scheduled program. Individual factor was identified since three anaesthesiologists out of 22 were responsible for 49% of omissions on duty and one nurse anesthetist was responsible for 18% of the use of a failed machine and 30% of the omission of the auto-test.


CONCLUSIONS
the auto-test of the anesthesia machine was correctly made in most cases but there are still situations where the checklist wasn't carried out. Therefore, the human factor seems important and justifies to be taken into account.
Service d'anesthésie et service biomédical, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France.
S
S
Suria
J-M
JM
Puizillout
P
P
Baguenard
J-L
JL
Bourgain
D000776:Anesthesiology / Q000295:instrumentation*; D057189:Checklist; D006801:Humans; D009873:Operating Rooms; D017751:Safety Management