Pre-Use Preparation and Checkout of Equipment

After the plan is established, the anesthetist must prepare the work environment. This involves obtaining necessary equipment and supplies, assembling infusions, preparing syringes of needed drugs, and conducting pre-use checkouts of life support equipment. The performance of anesthetists at these tasks is not optimal. Buffington and colleagues^[189] demonstrated that only 3% of anesthetists examining an anesthesia machine could identify all five faults with which it had been rigged; most practitioners found only two of the five. Nearly 30% missed such major faults as the complete absence of both unidirectional valve disks in a circle anesthesia breathing system and a swap of the nitrous oxide and oxygen cylinders (made possible by a fault in the pin-indexing system).

The FDA, in cooperation with the ASA, the Anesthesia Patient Safety Foundation (APSF), and experts from academics and industry, developed a set of recommendations for the checkout of anesthesia apparatus.^[190] This checklist was widely disseminated by the ASA and the APSF. However, it was found that use of the checkout procedure was minimal and that the extent of pre-use checkout by practitioners was extremely variable. A newer study^[191] was conducted to compare the checkout of anesthesia machines by practitioners with and without the use of the FDA checkout procedure. Most of the faults were detected by 50% or fewer participants, regardless of the checkout procedure used. Only for one fault, the failure of the oxygen/nitrous oxide ratio protection system, did the FDA checklist offer significant advantages; when using it, the detection rate increased to 65%. Interestingly, 34% of faults that were not detected were missed by practitioners who had in fact correctly answered three out of three written test questions concerning that fault. This suggests that although some of the performance deficit may be related to a lack of knowledge, a substantial proportion is due to the inability to apply abstract knowledge to the practical performance of equipment checkout.

There were many criticisms of the original checklist, particularly of its complexity.^[192] A streamlined version of the original checklist was published by the FDA in 1993.^[193] A study of the new checklist showed no significant benefit from its use and a disturbingly low rate of detection of machine faults (around 50 %).^[194] In another study, anesthetists using a highly interactive electronic checklist (developed by Blike and Biddle) improved their detection of "easy faults" but still missed a high proportion of difficult faults.^[195] A study performed more recently to measure the influence of fatigue on performance in a simulator showed that subjects in both the rested and fatigued conditions left out significant portions of the machine check.^[196]