Equipment Failure: An Analysis of 2000 Incident Reports

Abstract

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 177 (9%) were due to “pure” equipment failure according to pre-defined criteria. Of these 107 (60%) involved anaesthetic equipment, 42 (24%) involved monitors, 17 (10%) other theatre equipment and 11 (6%) the gas or electricity supply. Ninety-seven (55% of the 177) were potentially life-threatening; of these two-thirds would be detected by the array of monitors recommended by the Australian and New Zealand College of Anaesthetists and all but 9 of the remainder would be handled by application of the crisis management algorithm recommended elsewhere in this symposium. Of the 9 remaining, 2 were electrical shock, 3 overheating of a humidifier or blood warmer, 2 the unavailability of a spare laryngoscope and 1 the consequence of a power failure. Meticulous adherence to the equipment checking and monitoring guidelines of the Australian and New Zealand College of Anaesthetists and application of a suitable crisis management algorithm should protect the patient from potentially life-threatening equipment failure in virtually all cases except electric shock, power failure and overheating of warming devices.