Alerts usually pertain to one product or product family from one manufacturer. However, in what looks like a most unusual step the UK’s MHRA has issued a generic alert relating to the use of Anaesthetic machines from all manufacturers.
The alert, which can be found here, is based on findings from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which reports that ‘failure to check the anaesthetic machine and/or the breathing system features as a major contributory factor in many anaesthetic misadventures, including some that have resulted in hypoxic brain damage or death’.
Action is required of anaesthetists, operating department practitioners, anaesthetic nurses and all staff using anaesthetic machines and associated devices as follows:
• Be aware that the AAGBI has published an updated version of ‘Checking Anaesthetic Equipment’ endorsed by all UK Chief Medical Officers and the Royal College of Anaesthetists. The new ‘Checklist for Anaesthetic Equipment 2012’ (attached to the alert).
• Always follow the manufacturer’s instructions for use.
• Check anaesthetic machines and all breathing system components before use.
So what’s behind the story? Well, we’re speculating, but it would appear that once the AAGBI had made its statement the MHRA decided it was time for a reminder to keep on top of the instrumentation and chose to use its Alert procedure to get the message out with due haste and in the most attention grabbing fashion. What’s causing slightly more bemusement here is that healthcare providers are obliged to keep on top of their equipment and employ departments or outsource the medical physics function for that exact purpose. Nevertheless it’s reassuring to see MHRA taking an active part in front line device use and healthcare delivery.