A&A Case Reports

Skip Navigation LinksHome > June 15, 2014 - Volume 2 - Issue 12 > Mask Induction Despite Circuit Obstruction: An Unrecognized...
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A&A Case Reports:
doi: 10.1213/XAA.0000000000000026
Case Reports: Case Report

Mask Induction Despite Circuit Obstruction: An Unrecognized Hazard of Relying on Automated Machine Check Technology

Yang, Kamie K. MD; Lewis, Ian H. MBBS, MRCP, FRCA

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Various equipment malfunctions of anesthesia gas delivery systems have been previously reported. Our profession increasingly uses technology as a means to prevent these errors. We report a case of a near-total anesthesia circuit obstruction that went undetected before the induction of anesthesia despite the use of automated machine check technology. This case highlights that automated machine check modules can fail to detect severe equipment failure and demonstrates how, even in this era of expanding technology, manual checks still remain essential components of safe care.

© 2014 International Anesthesia Research Society

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