2025 FSA Podium and Poster Abstracts

The anesthesia machine is one of the most complex and essential pieces of equipment in the operating room, combining critical functions such as ventilation, vaporization, gas analysis, and scavenging. Ensuring its safe operation is paramount, and anesthesia providers are responsible for checking the machine's components daily. While many checks are automated, some require direct physical inspection by the provider to ensure everything is intact. In many hospitals, anesthesia technicians assist with these checks, but the ultimate responsibility for patient safety falls on the anesthesiologist.

During a locum assignment at a hospital with ten operating rooms, the author became aware of complaints from staff in one operating room, who reported frequent headaches. This raised concerns about unsafe levels of anesthetic gases in the room. Upon investigation, it was discovered that several anesthesia providers were not performing thorough safety checks, which led to a crucial issue going unnoticed, an environmental services employee had been inadvertently turning off the scavenger system. This failure resulted in the accumulation of waste gases, likely contributing to the reported symptoms.

This was a preventable error. By following the chain of command and investigating those with access to the scavenger system, the root cause was identified. The solution involved an inservice for the operating room staff and the addition of a label on the scavenger to remind staff of its importance and proper operation.

This experience underscores the need for a clear routine and accountability in safety checks, as well as periodic reviews to ensure they are being carried out correctly. Ongoing process improvement, combined with strong communication and oversight, is critical to preventing errors. In the end, safety in the operating room is a shared responsibility, and fostering open communication can significantly reduce errors and protect patients.