The College Of Anaesthetists

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Safety Advisory Notices 



"Inj Light" syringes when used in syringe pumps. See attached safety syringe advisory notice below



Standards of monitoring during Anaesthesia  November 2017


You will most probably be aware of a recent high profile case in which a patient suffered hypoxic brain injury during the course of surgery and anaesthesia. The anaesthetist in the case received Medical Council Sanction for leaving the patient for a period of time during the case in the care of a nurse. The College and the National Clinical Programme for Anaesthesia have now been asked by the HSE as to whether this may be occurring more commonly.  We have advised them that a core element of our professional practice is to be present and care for the patient throughout the course of an anaesthetic and that to do otherwise was not acceptable practice.  We are taking this opportunity to circulate the AAGBI Standards for Monitoring (2015) in which this is made explicitly clear at standard 1.  We expect every anaesthetist and every Anaesthesia Department in the country to ensure  compliance with this standard.


Medical Gas Cylinders Expiry Date - August 2017


Dr Stephen Mannion from the South Infirmary-Victoria University Hospital in Cork draws our attention to a situation where a hospital failed a gas supply safety check because the cylinders had passed their expiry dates. Please see below content of this email in full for your information.


'Our hospital recently failed a gas supply safety check because all the oxygen, nitrous oxide and air cylinders on all anaesthesia machines were out of date although all were full. As our hospital has consultants from Cork University Hospital working daily on site, it seems not to be unique to our institution. Checking the expiry dates is not part of the AAGBI checklist and may explain this finding. Unfortunately all cylinders have only a 1 (oxygen) to 2 (N20) year expiry dates. I suspect most anaesthetists are not aware of this issue and are (rightly) more concerned with whether the cylinders are full or not. I am not sure if this is a “safety” issue but the regulations require that they are in date. To rectify the situation in our hospital, the Portering Department will change all OXYGEN cylinders the week before the NCHD changeover in July each year and anaesthesia staff have been made aware of the issue. In terms of having nitrous oxide and air on the back of anaesthesia machines; based on how little to never they are used and the fact that they are not essential in the case of main gas supply failure, a proposal could be made that all nitrous oxide and air cylinders are permanently removed from anaesthesia machines'.


We advise that you confirm in your own hospital as to what arrangements/procedures are in place to check expiry dates on Medical Gas Cylinders.


Portable Medical Oxygen Cylinders Fire Risk - August 2017


The Health & Safety Authority (HSA) have issued an advisory notice about the use of portable oxygen cylinders. This followed a recent fatal accident in an ambulance. Please visit link to HSA website for further information:  


Safety Advisory Notice - June 2017


Please see below attachment for 'June 2017'.


Medical Gas Cylinders - February 2017


To improve identification of medical gas cylinders and bring them in line with European standards, the HPRA has approved changes to the colour coding of cylinders to reduce the risk of administering the wrong gas to the patient. In future, to distinguish medical gas cylinders from non-medical cylinders, the medical cylinder bodies will be white. The shoulder colours will not change, and these will identify the individual gases. Cylinders will also carry the name of the medical gas in large letters on the cylinder body to help identification.


Please see below attachment, 'New "White" appearance for medical gas cylinders', from BOC for further information. 


King Laryngeal Tube - January 2017


Please see below attachment for 'King Laryngeal Tube'.


Download this file (BOC - New “White” appearance for edical gas cylinders.pdf)New “White” appearance for medical gas cylinders[New “White” appearance for medical gas cylinders]2092 kB
Download this file (Safety Advisory Notice June 2017.pdf)Safety Advisory Notice June 2017[Safety Advisory Notice June 2017]266 kB
Download this file (Safety Advisory Notice King Laryngeal Tube.pdf)Safety Advisory Notice – “King Laryngeal Tube “[Safety Advisory Notice – “King Laryngeal Tube “]228 kB
Download this file (Urgent - SafetySyringesdrivers.pdf)Urgent - SafetySyringesdrivers.pdf[ ]914 kB