Case 83: A Potentially Serious Incident

Abstract

Today you are in the endoscopy suite. On entering the procedure room, you note that the anesthesia machine is an older version of the one you use in the rest of the hospital. You check the anesthesia machine and find everything is in order. There is piped oxygen into the procedure room and the emergency oxygen and nitrous oxide cylinders on the back of the machine are full. A large see-through plastic bag with an Ambu bag is hanging on the side of the anesthesia machine beside the absorber. You now recall that at a departmental morbidity and mortality (M&M) meeting there had been an incident of a sudden anesthesia machine failure in the endoscopy suite. You check the Ambu bag and find it in order. You ask that a separate full cylinder of oxygen be brought into the procedure room. This is to be used with the Ambu bag to provide a higher inspired oxygen concentration, in case the anesthesia machine stops functioning.