[HOSPITAL NAME]
Equipment Safety & Readiness Program
Anesthesia Machine
Daily Checkout Log
Mandatory pre-use safety inspection aligned with ASA guidelines.
Machine ID / Asset Number
System Boot & Self-Test
Power cord plugged into emergency outlet. Machine boots normally. Automated self-test passed with no critical errors.
Pipeline Gas Pressures
O₂, N₂O, and Medical Air pipeline pressures are within normal range (≥ 50 psi).
Backup Oxygen Cylinder
Cylinder present, securely mounted, opened to confirm adequate pressure (>1000 psi), and closed after checking.
Oxygen Sensor / Analyzer
Calibrated and reads ~21% in room air. Alarms function appropriately.
Vaporizer Installation & Levels
Vaporizers are correctly seated, locked, adequately filled, filler caps are tight, and dials are in OFF position.
Circuit Assembly & Leak Test
Circuit correctly assembled. Leak test performed and passed. Unidirectional valves functioning properly.
CO₂ Absorbent
Canister securely seated. Color indicates adequate absorption capacity (not exhausted).
Ventilator Function & Alarms
Ventilator modes operate correctly. High pressure, low pressure, and apnea/disconnect alarms are enabled and audible.
Suction Apparatus
Connected, turned on, and generating adequate vacuum. Tubing and Yankauer/catheter present.
Scavenging System
Waste gas scavenging system properly connected and flow adjusted correctly.
Manual Resuscitator (BVM)
Self-inflating bag (Ambu bag) immediately available in room for emergency ventilation.
Faults Reported / Corrective Actions (If any check marked FAIL)
Overall Machine Status
Do not use for patient care if safety-critical faults exist.
Checked By (Anesthesia Tech / Nurse / Physician)
Signature / Print Name
Verified By (Anesthesia Provider - Prior to first case)
Signature / Print Name
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