One Liners issue 70 - July 2009

The Safety Committee of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) have reported incidents of failure in the battery back-up of anaesthetic machines. Power supply failures in hospitals are not uncommon; however, the majority of anaesthetic machines have an integral battery as back-up in the event of power cuts.

The aim of this sheet is to briefly detail the concerns of the AAGBI and highlight their recommendations. Device failures, including those involving anaesthetic machines and their associated patient monitors, should be reported to MHRA Adverse Incident Centre, aic@mhra.gsi.gov.uk, Hotline: 020 7084 3080

Check mate!
All anaesthetic equipment should be checked before induction of anaesthesia in accordance with the manufacturer’s instructions and the AAGBI Guideline (Checking anaesthesia equipment).

• This can be found at The Association of Anaesthetists of Great Britain and Ireland's Checking Anaesthetic Equipment (external link)

Check erred history?
Modern anaesthetic machines will asses the functionality of the back-up battery in their self test on start up.

• Any warnings on the condition of the battery should be reported to the Service Department and advice obtained on continued machine use.

CELLnescent
The age and condition of the back-up batteries in anaesthetic machines, and associated patient monitors, should be checked at regular intervals. Electrical sockets on the machine may not function on battery back-up, therefore essential monitoring devices may require independent battery back up.

• All departments should have a programme in place for the checking and replacement of all back-up batteries, as recommended by their manufacturers.

You ’til at ease!
When the anaesthetic machine is running on the back-up battery the gas supply should not be affected. Any failure in the gas supply on back-up battery should be reported immediately to the servicing department.

• The machine must not be used again until the fault is corrected and the machine tested.

Fall from grace?
If external battery packs or monitors have been dropped or damaged, this must be reported immediately to the servicing department.

• It must not be used until it has been inspected, repaired and tested if appropriate.

Limited current see!
In the event of a mains power supply failure, the back-up battery should be used only to allow time to transfer the patient to an independent anaesthetic breathing circuit and monitors.

• It is not recommended for the maintenance of anaesthesia.

The One Liners Editions are published by the MHRA, an executive agency of the Department of Health.

Adverse incidents should be reported at the earliest opportunity. We prefer to receive reports via the online reporting system on our website.

You may also use this online system to send an e-mail copy of your report to your medical device liaison officer.

We also have an adverse incident hotline: 020 7084 3080. You can find detailed reporting guidance on our website.