Checklists Cited as Contributing to Safety

J. E. Charlton

Editor’s Note: The following is an editorial from Anesthesia (I 990;45:425) reprinted with permission from the author and publisher.

Most anaesthetists ensure there has been some check of an anaesthetic machine before its use. (1) This procedure may entail the use of a formal checklist, or it may be a more rudimentary version of the ‘kick the tyres, slam the doors, turn the lights on and off’ kind. The latter method is akin to a pilot throwing his leather jacket over the back of the seat with merry cries of ‘chocks away’; then off into the wide blue yonder, and it is only a matter of time before a ‘wizard prang’ occurs!

Those of us used to the relatively unsophisticated anesthetic machines of the 60s and 70s may make basic mistakes when confronted with one of the ‘mighty Wurlitzer’ variety that are becoming more common. Checklists have been available for some time and yet there is ample evidence to suggest that their application is by no means universal (2) despite the fact that many fists were introduced after a serious accident with an anaesthetic machine. (3) The argument follows from this that it is both reasonable and prudent to introduce mandatory checklists as an aid to patient safety.

The United States of America is in the forefront of the introduction of mandatory checklists. The Food and Drug Administration introduced anaesthesia apparatus checkout recommendations in August 1986. The preamble states ‘this checkout, or a reasonable equivalent, should be conducted before anesthesia. This is a guideline which users are encouraged to modify to accommodate differences in equipment design and variations in local clinical practice. Such local modifications should have appropriate peer review. (4) Recommendations from a federal body that contain the word ‘should’ are not voluntary; they are mandatory.

An Association of Anaesthetists of Great Britain and Ireland Working Party has considered the matter of checklists. (5) The Working Party does not suggest that checklists be mandatory as they are in other countries like the U.S.A., Australia and Germany. The Association does not work by prescription, but responds to the demands and needs of its members. The Association has responded in this instance, by obtaining the best advice and passing it on to the membership to do as it pleases. Nevertheless, an ‘Association view’ is clearly stated. The report recommends that anaesthetic machine check procedures should be performed at the beginning of each operating theatre session.

The anaesthetic machine is a key component of safety, and more and more machines will have automatic monitors build into them to provide added vigilance over both machine and patient. System oxygen concentration and exhaled patient volume monitors may provide early warning of hypoxic mixtures, system leaks or accidental disconnections. Integration of these and other monitors (capnometry, pulse oximetry, noninvasive blood pressure) into the anesthesia system helps to ensure that monitors are switched on and functional before activation of gas delivery and improves the management of the multiple machine and patient connections. (6)

The argument has been advanced that a simple check at the beginning of anesthesia is sufficient, and that any faults will be picked up and dealt with intraoperatively. This may be true in the majority of cases, but modern anesthetic machines are both large and complex: They need to be checked carefully to avoid potential problems. It is just as important to check the older, simpler machines as they approach the end of their working lives. Many hospitals may have found it difficult to replace older machines because of restraints placed upon their equipment budgets.

U.K. Recommendations

The anaesthetic machine checking procedure recommended by the Working Party is simple, and should ensure high compliance. It is not intended to replace schemes devised by individual manufacturers for their machines. The belief of the Working Party is that the introduction of a checklist based on the use of an oxygen analyzer will mean safer practice. This piece of equipment therefore, will become standard. It is pleasant to speculate on the prospect of managers dashing round to anaesthetic departments to offer extra money for such equipment, having be-en won over by the argument that anything that will increase patient safety and reduce the possibility of litigation and thus cost, is a worthwhile use of their hard-won resources.

Performance of such checks forms part of our working day and should not be viewed as an additional burden. However, the concept of making a preanesthetic machine check compulsory is both controversial and provocative. There will be arguments that checks are already carried out by qualified personnel such as anaesthetic nurses, operating department assistants (ODAs), and that for the anaesthetist to repeat them would be a time-consuming reduplication of effort.

The question of who should carry out the checks has already been raised by members who have tried out the proposed checklist after it was circulated for comment. Them is no doubt in the writer’s mind that the anaesthetist must check the anaesth6c machine before a theatre session, since ultimate responsibility lies with the anesthetist and cannot be delegated or denied. This does not mean that the anaesthetist should carry out every part of the check personally. It is probably sufficient for the check to be carried out by the anesthetist with another appropriately trained person who could be a nurse or ODA, rather as pilot and copilot check before take-off. This suggestion has the additional advantage that the time taken to perform the check would be reduced.

The report also suggests that a written record of the check he kept in either a specific logbook or on the patient’s anaesthesia record. Is this necessary? A simple test of negligence is whether or not the anaesthetist has maintained a reasonable standard of care in treating the patient. A standard of care is, in general, determined by review of written records and the importance of good record keeping is emphasized every year by the defense organizations in their annual reports. Records made today may have to be defended many years from now. A general rule says ‘if it isn’t written down, it wasn’t done.’ Keeping a written record of check procedures makes sense.7

There may be other potential benefits. Anaesthetists in the United States have found that their malpractice insurance can be reduced by declarations that they have adopted and abide by checklist procedures and minimal monitoring standards. They are paying the same rates as general practitioners in some states ! This may he an idea that could be taken to our defense organizations.

It is recognized that it may not be possible to carry out a full check in an emergency situation. This should not be a problem where there is a dedicated emergency theatre since it should have been possible to check the machine at an earlier time. Should a true emergency occur it is unreasonable to insist that a full check be carried out, but it would seem reasonable to document the circumstances when time permits.

The recommendations for standards of monitoring published by the Association in July 1988 were “somewhat watered-down before publication because some members of Council had strongly objected to too many words such as ‘must’ ” (9) Times change, and by the College of

Anaesthetists’ symposium in November of the year the recommendations were thought to be in need of strengthening. The current mood seems to favour the adoption of higher standards of safety and patient care. The use of checking procedures seems an excellent way to achieve these objectives.

Recent articles have suggested that the introduction of checklists may be a potent factor in reducing both the number and frequency of critical incidents during anaesthesia (10) and that use of checklists and adequate monitoring with current technology may avoid up to 50% of patient injuries: this makes these procedures cost effective in injury prevention. (11) However, we should never forget that one of the many corollaries to Murphy’s Law applies; ‘it is impossible to make anything foolproof because fools are so ingenious’ (12)

Dr. Charlton is Assistant Honourary Secretary of the Association of Anaesthetists of Great Britain, Ireland and London.


1. Association of Anesthetists of Great Britain and Ireland. Report of the Survey of Anaesthetic Practice, 1988.

2. Graig 1, Wilson ME. A survey of anaesthetic misadventure. Anaesthesia 1981: 36: 933-6.

3. Leading article. the Westminster inquiry. Lancet 1977: ii: 175-6.

4. Food and Drug Administration. Anesthesia Apparatus Checkout Recommendations. Anesthesia Patient Safety Foundation Newsletter 1986; 1. 15.

5. Association of Anesthetists of Great Britain and Ireland. Checklist for an anesthetic machines. A recommended procedure based on the use of an oxygen analyzer. To be published. 1990.

6. Berssenbrugge A, Plantes K. Anesthesia machine key component of safety. Anesthesia Patient Safety Foundation Newsletter 1986; 1: 16.

7. American Society of Anesthesiologists. Professional liability and the anesthesiologist. Park Ridge, Illinois, 1987.

8. Sabella JD. CA insurer notes fewer claims, lower premiums. Anesthesia Patient Safety Foundation Newsletter 1987; 2:22.

9. Adams AP. Recommendations for monitoring standards in the U. K. and Ireland. Anesthesia Patient Safety Foundation Newsletter 1989; 3. 32-3.

10. Kumar V, Barcellos WA, Mehta MP, Carter JG. An analysis of critical incidents in the teaching department for quality assurance A survey of mishaps during anaesthesia. Anaesthesia 1988; 43: 879-83.

11. Whitcher C, Ream AK, Parsons D, Rubsamen D, Scott 1, Champeau M, Sterman W, Siegel L. Anesthetic mishaps and the cost of monitoring: a proposed standard for monitoring equipment. Journal of clinical Monitoring 1988; 4:5-15.

12. Martin TL Jr. Malice in Sunderland New York: McGraw Hill, 1973.