Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

Disclaimer:
Any hardcopy, printed or photocopied, is considered an uncontrolled copy, unless it is the original,
signed-off version from Medical Affairs and Quality Department.

Review & Approval

Name Designation Date Signature

Prepared by
: Nur Lisa Binti Hamzah Nurse Manager

Reviewed by
1 Dr Muhammad Nahar Anesthetist

Director Of
2 Katini Abu Hassan
Nursing

Acting Assistant
3 Nooraida Mat Radzi
Manager, MAQ

Approved by Chief Operating

: Ms Tio Bee Chan
Officer
 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

Document Revision History

Date Version Description of Revision

02-09-2012 0 Initial release.
Changed COO Tan Seang Aun to Mohd Shafee Awang.
30-05-2013 1.0
Renamed Nursing Supervisor to Nurse Manager.
All the document shall be reviewed regularly eithin 3 years by the
respective department to determine its suitability and relevancy.
22-08-2016 2.0
(HOP-QA-01. Clause 13.1)
Changed COO Mohd Shafee Awang to CEO Pan Wen Lek.
10-10-2017 3.0 Changed CEO Pan Wen Lek to COO Tio Bee Chan
Changed to new templete

Page 2 of 7
 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

TABLE OF CONTENTS

1.0 PURPOSE ................................................................................................................................... 4

2.0 SCOPE ........................................................................................................................................ 4

3.0 RESPONSIBILITY ...................................................................................................................... 4

4.0 ABBREVIATION ......................................................................................................................... 4

5.0 DEFINITIONS.............................................................................................................................. 4

6.0 POLICY ....................................................................................................................................... 5

7.0 FLOW CHART ............................................................................................................................ 5

8.0 GUIDELINE & PROCEDURES................................................................................................... 5

9.0 QUALITY IMPROVEMENT MONITORING ................................................................................ 7

10.0 REFERENCES ............................................................................................................................ 7

11.0 APPENDICES ............................................................................................................................. 7

Page 3 of 7
 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

1.0 PURPOSE

To ensure functional anesthetic machine for staff and patient safety.

2.0 SCOPE

Daily checking and before commencement of surgery/ anesthesia for every patient

to ensure the machine (Anesthetic) in functional.

3.0 RESPONSIBILITY

3.1 Anesthetist

3.2 Staff Nurse (GA NURSE)

4.0 ABBREVIATION

5.0 DEFINITIONS

The anesthesia machine performs four essential functions:

1. Provides O2,

2. Accurately mixes anaesthetic gases and vapours,

3. Enables patient ventilation and

4. Minimises anaesthesia related risks to patients and staff

Page 4 of 7
 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

6.0 POLICY

6.1 It is essential to provide a safe and protected environment for the patients and also

staffs in operating theatre

6.2 Safe practice within the operating theatre should be used in conjunction with the safety

programs outlined in the policies of the hospital.

7.0 FLOW CHART

NIL

8.0 GUIDELINE & PROCEDURES

8.1 INTRODUCTION

8.1.1 The regulated supply of gases and vapours for anaesthesia and the provision of
controlled ventilation for the patient are the main functions of the anaesthetic
machine. Because oxygenation and ventilation are essential for every patient and
because even a brief failure to maintain them may cause irreparable harm, every
machine must be regularly and thoroughly checked to ensure that all functions are
correctly maintained.

8.1.2 There must always be reserve facility to maintain oxygenation and ventilation of a
patient should failure of the primary systems occur.

8.1.3 To ensure early detection of any failure in the anaesthetic machine, it is essential that
appropriate alarms are present in the machine.

8.2 LEVEL OF CHECKING

8.2.1 Level One checks

These are very detailed and are required on any new machine and on all machines

after the required regular servicing.

8.2.2 Level Two checks

These should be performed daily at the start each anaesthetic session.

8.2.3 Level Three checks

These should be performed each time before a patient is put under general

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 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

anaesthesia.

Each check must be derived specifically for the machine under test and the
Anaesthetic Department (on behalf of the hospital administration) is responsible for
the training and accreditation of the personnel involved with each test.

8.3 ACCREDITATION FOR CHECKING THE ANAESTHETIC MACHINE REQUIRES:

8.3.1 Level One

Attendance at a manufacturer’s course or by attendance at a programme

developed
jointly by the hospital’s Bioengineering and Anaesthetic Departments.

8.3.2 Level Two

Checks must follow protocols specifically developed for the machine under test. All
personnel must be trained in correct procedures and accredited to perform them by
the Anaesthetic Department. The specific protocols should be attached to the
machine.

8.3.3 The Hospital Anaesthetic Department or body responsible for the equipment shall
keep a detailed record of the equipment and the checking procedures. This process
requires that a checklist be maintained. The checklist will be based on manufacturer’s
guidelines and on Biomedical Engineers and Anaesthetic Department
recommendations. The protocol shall describe checking and calibration protocols and
the intervals at which these must be performed.

8.3.4 The anaesthetic machine must have a prominent label to advise of past service(s)
and to indicate when the next check is due. This label must be visible to the
anaesthetists.

8.3.5 Gas Delivery System

The check shall include:

8.3.5.1 Quantifying and minimizing leaks.

8.3.5.2 Excluding crossed pipeline within the machine.

8.3.5.3 Ascertaining the correct functioning of non-return valves throughout the

system.

Page 6 of 7
 Private & Confidential

Pantai Hospital Sungai Petani

Standard Operating Policy and Procedure
Document Title: Process Owner:
Checking Functioning Of Anesthetic Machine Operating Theatre

Reference No.: Version No.: Controlled Original Date:

Copy No.: 02/09/2012
PHSP_NUR.OPE_POL_002 3.0 0 – Original Effective Date:
1/1 - Copy 10/10/2017

8.3.6 Anaesthetic Vapour Delivery System

The check shall include:

8.3.6.1 The method and accuracy of vapour output and delivery devices.

8.3.6.2 The calibration of vapour output devices and monitors.

8.3.6.3 A formal check of compliance of all components of the machine or part of

the machine.

9.0 QUALITY IMPROVEMENT MONITORING

9.1 Zero Percentage of intraoperative complication of anesthesia – aspiration pneumonia

9.2 Zero Percentage of intraoperative complications of anesthesia – cardiac events

10.0 REFERENCES

Gurudatt, C. (2013). The Basic Anaesthesia Machine. Indian Journal of Anaesthesia, 57(5), 438–445.
http://doi.org/10.4103/0019-5049.120138

Goneppanavar, U., & Prabhu, M. (2013). Anaesthesia Machine: Checklist, Hazards,

Scavenging. Indian Journal of Anaesthesia, 57(5), 533–540. http://doi.org/10.4103/0019-5049.120151

11.0 APPENDICES

Serial Retention
Form No. Form Title Location Appendix
No. Period
Checklist for GA machine Ohmeda Refer MR Nil
1 R-OPE-013 OPE
Excel Policy
Refer MR Nil
2 R-OPE-014 Checklist for GA machine Aspire OPE
Policy

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