Safety in Safety in AnesthesiaAnesthesia

Dr Lin CaoDr Lin CaoDepartment of Anesthesia,Department of Anesthesia,

22ndnd affiliated hospital, affiliated hospital,Sun Yat-Sen UniversitySun Yat-Sen University

Anesthetists are responsible for patient safety Anesthetists are responsible for patient safety during operations during operations

Anesthesiology is a high-risk specialty as Anesthesiology is a high-risk specialty as compared with other specialties in medicinecompared with other specialties in medicine

Why

The risk of anesthesiaThe risk of anesthesia Anesthesia may contribute to death Anesthesia may contribute to death

in about 1 per 10,000 anesthetics. in about 1 per 10,000 anesthetics.

Many other patients suffer serious Many other patients suffer serious and costly nonfatal injuries such as and costly nonfatal injuries such as permanent neurologic damage permanent neurologic damage (paraplegia and vegetative). (paraplegia and vegetative).

Now we can see anesthesia event Now we can see anesthesia event can cause severe resultscan cause severe results

So we should find out factors So we should find out factors threatening patient safety in the threatening patient safety in the operation room and search for operation room and search for strategies to deal with themstrategies to deal with them

There are many factors threatening There are many factors threatening patient safety in the operation roomspatient safety in the operation rooms

EquipmentEquipment Causes: Causes:

Design flawDesign flaw User errorUser error MalfunctionMalfunction

Strategies: pre-use checkoutStrategies: pre-use checkout

PatientPatient

CausesCauses Underlying diseases: hyperthyroidism-thUnderlying diseases: hyperthyroidism-th

yroid storm, diabetes-ketoacidosis or hypeyroid storm, diabetes-ketoacidosis or hyperosmolar comarosmolar coma

Allergic reaction to some drugAllergic reaction to some drug StrategiesStrategies

Preoperative evaluationsPreoperative evaluations

Anesthetist and SurgeonAnesthetist and Surgeon

Human factors affecting Human factors affecting performance such as :fatigue, noise, performance such as :fatigue, noise, boredom, long hours, hunger, boredom, long hours, hunger, tensiontension

Causes for Accidents Causes for Accidents

There is rarely a single cause for There is rarely a single cause for an accident. an accident.

System failures are the main reason foSystem failures are the main reason for accidentsr accidents check anesthetic machinecheck anesthetic machine oxygen supplyoxygen supply A backup O2 tank A backup O2 tank Never shut down audible alarms (very imNever shut down audible alarms (very im

portant)portant)

Emergency ventilation Emergency ventilation equipmentequipment

Human error is a strong Human error is a strong contributorcontributor

Deviations from accepted anesthesia Deviations from accepted anesthesia practices.practices.

A lapse in vigilance and no attention to A lapse in vigilance and no attention to detail detail

Vigilance and attention to detail Vigilance and attention to detail are essential for a safely are essential for a safely conducted anesthetic.conducted anesthetic.

Vigilance lets anesthetists find Vigilance lets anesthetists find abnormal signs as early as possibleabnormal signs as early as possible

Vigilance allows the anesthetist to remaiVigilance allows the anesthetist to remain aware of surrounding events and signaln aware of surrounding events and signals while performing other tasks. s while performing other tasks.

II. General safety strategiesII. General safety strategies

A. Prepare a preoperative A. Prepare a preoperative planplan

..

Preoperative visit to the paPreoperative visit to the patient to let us know the pattient to let us know the patient’s condition in detailient’s condition in detail

Make an anesthesia plan tMake an anesthesia plan to let us know clearly how to let us know clearly how to perform the anesthesia ao perform the anesthesia and how to deal with possibnd how to deal with possible crisis le crisis

Check anesthesia machine Check anesthesia machine ,monitors and other device,monitors and other devicess

Prepare the workspace to Prepare the workspace to make us work more convemake us work more conveniently and efficiently. Arrniently and efficiently. Arrange equipment and approange equipment and appropriate monitors in a way thpriate monitors in a way that facilitates this. So we caat facilitates this. So we can clearly observe the patien clearly observe the patient and easily manipulate alnt and easily manipulate all devicesl devices

Check backup Check backup equipmentequipment

Know the location Know the location of emergency of emergency supplies and supplies and equipmentequipment

Label all medicationsLabel all medications

B. Develop situational B. Develop situational awarenessawareness

Use a systematic approach to scanning Use a systematic approach to scanning the machine, monitors, patient, surgical the machine, monitors, patient, surgical field, and surroundings.field, and surroundings.

If one vital sign is anomalous, quickly If one vital sign is anomalous, quickly assess the others while repeating the assess the others while repeating the measurement and observing what is measurement and observing what is happening on the surgical field.happening on the surgical field.

C. Verify observationsC. Verify observations

Cross-check observations Cross-check observations Assess covarying variables Assess covarying variables Review it with a second person. Review it with a second person.

D. Implement compensatory D. Implement compensatory responsesresponses

If something wrong happens urgently, If something wrong happens urgently, first implementing time-buying measufirst implementing time-buying measures. e.g., increase the fraction of inspires. e.g., increase the fraction of inspired oxygen when oxygen saturation falred oxygen when oxygen saturation falls; administer intravenous fluids or vasls; administer intravenous fluids or vasopressors when hypotension occurs). opressors when hypotension occurs).

Then search out any correctable primaThen search out any correctable primary cause and treat it appropriately ry cause and treat it appropriately

E. Prepare for crisisE. Prepare for crisis If there is any critical events If there is any critical events

happened (cardiac arrest, malignant happened (cardiac arrest, malignant hyperthermia or difficult intubation), hyperthermia or difficult intubation), call for help early (WHY), then use call for help early (WHY), then use accepted protocols for emergencies accepted protocols for emergencies and resuscitation (e.g., advanced and resuscitation (e.g., advanced cardiac life support, malignant cardiac life support, malignant hyperthermia protocols).hyperthermia protocols).

F. Enhance teamwork; F. Enhance teamwork; communicatecommunicate

To enhance teamwork and To enhance teamwork and communication, address surgeons communication, address surgeons and nurses early in the case by and nurses early in the case by knowing names. Make requests and knowing names. Make requests and delegate tasks clearly and delegate tasks clearly and specifically by name (e.g., “Jack, do specifically by name (e.g., “Jack, do task X and tell me when task X is task X and tell me when task X is completed.”). completed.”).

G. Compensate for G. Compensate for stressorsstressors

Anesthetist is a stressful job. If you Anesthetist is a stressful job. If you feel very tired, ask for a relief. feel very tired, ask for a relief.

Reduce various stressors: noise, Reduce various stressors: noise, fatigue, interpersonal tension, etc. fatigue, interpersonal tension, etc. optimize the work environment .optimize the work environment .

H. Recognize and address H. Recognize and address production pressuresproduction pressures

Patient safety must remain the highest Patient safety must remain the highest priority priority

In big hospitals, anesthetists have a great In big hospitals, anesthetists have a great deal of workload. There are many operations deal of workload. There are many operations everyday. Anytime we can’t sacrifice patient everyday. Anytime we can’t sacrifice patient safety in order to emphasize production. If safety in order to emphasize production. If there is no adequate preoperative evaluation, there is no adequate preoperative evaluation, preparation, or monitoring, it is unsafe to preparation, or monitoring, it is unsafe to anesthetize the patient. You must address anesthetize the patient. You must address concerns explicitly to surgeons and cancel concerns explicitly to surgeons and cancel the operation.the operation.

I. Learn from close callsI. Learn from close calls

Every mistake is an opportunity to Every mistake is an opportunity to learn and improve. learn and improve.

Analysis and feedback of adverse Analysis and feedback of adverse events to identify and assess system events to identify and assess system problems problems

III. Crucial errors to know and III. Crucial errors to know and avoidavoid

A. Airway errorsA. Airway errors

As we know, patients receiving general anesAs we know, patients receiving general anesthesia have no spontaneous respiration due thesia have no spontaneous respiration due to use of muscular relaxants, their respiratioto use of muscular relaxants, their respiration is controlled by machine via endo-tracheal n is controlled by machine via endo-tracheal tube. So we must ensure oxygen supply and tube. So we must ensure oxygen supply and avoid accidental extubation during sugeriesavoid accidental extubation during sugeries(esp a prone surgery) and transport. Once it (esp a prone surgery) and transport. Once it happens, the result is severe. It can cause sehappens, the result is severe. It can cause severe hypoxia and directly threaten the patievere hypoxia and directly threaten the patient life.nt life.

prone positionprone position

How to avoidHow to avoid

Check the system and guarantee it to fCheck the system and guarantee it to function wellunction well

Verify an endotracheal tube by auscultVerify an endotracheal tube by auscultating for breath sounds bilaterally and ating for breath sounds bilaterally and by detecting end-tidal COby detecting end-tidal CO22

Fix the tube solidlyFix the tube solidly Closely observe vital signsClosely observe vital signs

Verify an endotracheal tubeVerify an endotracheal tube

B. Medication errorsB. Medication errors

Administration of undiluted potassium by Administration of undiluted potassium by rapid intravenous infusionrapid intravenous infusion can cause ventr can cause ventricular fibrillation and cardiac arrest.icular fibrillation and cardiac arrest.

Neostigmine given without an antimuscariNeostigmine given without an antimuscarinic drug nic drug can cause asystole, severe bradycarcan cause asystole, severe bradycardia and atrioventricular block and can be fatdia and atrioventricular block and can be fatal.al.

Succinylcholine Succinylcholine can cause severe hyperkalecan cause severe hyperkalemia and dysrhythmias, may trigger malignamia and dysrhythmias, may trigger malignant hyperthermia.nt hyperthermia.

MedicationsMedications to which a patient is alle to which a patient is allergic can cause anaphylaxis. rgic can cause anaphylaxis.

Administering the wrong bloodAdministering the wrong blood can c can cause an incompatibility reaction that cause an incompatibility reaction that can be fatal.an be fatal.

How to avoid How to avoid

Be Familiar with the medication you use, Be Familiar with the medication you use, know clearly its indications and know clearly its indications and contraindications.contraindications.

Administrate the medication strictly according Administrate the medication strictly according to instructions.to instructions.

Know the patient’s history of allergyKnow the patient’s history of allergy Cross-check blood typeCross-check blood type

C. Procedure errorsC. Procedure errors InadvertentInadvertent intravascular injection of local intravascular injection of local

anesthetics anesthetics during a nerve block can cause nduring a nerve block can cause neurologic and cardiac toxicity, which can be feurologic and cardiac toxicity, which can be fatal (especially with bupivacaine).atal (especially with bupivacaine).

Avoidable epidural hematomas Avoidable epidural hematomas may develomay develop when spinal or epidural anesthetics are perfp when spinal or epidural anesthetics are performed in patients who have coagulopathies.ormed in patients who have coagulopathies.

Air embolisms Air embolisms may occur during the placemmay occur during the placement or removal of central venous catheters anent or removal of central venous catheters and may cause significant hemodynamic instabid may cause significant hemodynamic instability. (lity. (decumbens position can avoid itdecumbens position can avoid it))

How to avoidHow to avoid

Adequate preoperative evaluation of Adequate preoperative evaluation of patientspatients

Manipulation according to standards Manipulation according to standards and guidelines. and guidelines.

VigilanceVigilance

IV. Quality assuranceIV. Quality assurance

The aim is improving the quality of The aim is improving the quality of care and minimizing the risk of care and minimizing the risk of injury from anesthesia.injury from anesthesia.

A. DocumentationA. Documentation

Any adverse events should be Any adverse events should be reported truthfully, discussed, reported truthfully, discussed, analyzed to identify causes and analyzed to identify causes and assess system problems. So we can assess system problems. So we can learn from them and develop learn from them and develop patterns to prevent recurrence. patterns to prevent recurrence.

B. Standards and guidelinesB. Standards and guidelines

Anesthesists should be aware of their iAnesthesists should be aware of their institution's safety policies and procedunstitution's safety policies and procedures. These should include those for mores. These should include those for monitoring, response to an adverse event, nitoring, response to an adverse event, handoff checklist, resuscitation protochandoff checklist, resuscitation protocols, perioperative testing, and any specols, perioperative testing, and any special procedures or practices for the use ial procedures or practices for the use of drugs, equipment, and supplies. of drugs, equipment, and supplies.

C. Safety trainingC. Safety training

Anesthesia providers should obtain Anesthesia providers should obtain training in safety to learn and maintain training in safety to learn and maintain basic skills. Simulation techniques basic skills. Simulation techniques should be used. In reality, for one should be used. In reality, for one doctor, the opportunity to confront a doctor, the opportunity to confront a critical event is rare, the best way to critical event is rare, the best way to learn critical-event management skills is learn critical-event management skills is using simulator. After training on using simulator. After training on simulator repeatedly, when crisis simulator repeatedly, when crisis happens, you can manage it efficiently.happens, you can manage it efficiently.

V. Standards and protocolsV. Standards and protocols

Standards for basic anesthetic Standards for basic anesthetic monitoringmonitoring

1. Qualified anesthesia personnel 1. Qualified anesthesia personnel shall be present in the room shall be present in the room throughout the course of all general throughout the course of all general anesthetics, regional anesthetics, anesthetics, regional anesthetics, and monitored anesthesia care.and monitored anesthesia care.

2. Continually evaluate2. Continually evaluate the patient's the patient's respiration ,circulation and temperature.respiration ,circulation and temperature.

2.1 Respiratory monitor2.1 Respiratory monitor

oxygenation oxygenation an oxygen analyzer an oxygen analyzer pulse oximeter pulse oximeter

ventilation ventilation clinical signs clinical signs capnometrycapnometry continual end-tidal carbon dioxide analysis must continual end-tidal carbon dioxide analysis must

be used with tracheal intubationbe used with tracheal intubation some form of monitoring with an audible alarm some form of monitoring with an audible alarm

must be used during mechanical ventilationmust be used during mechanical ventilation

2.2 Cardiacvascular monit2.2 Cardiacvascular monitoror

continuous EKGcontinuous EKG blood pressure and heart rate at least eblood pressure and heart rate at least e

very 5 minvery 5 min one or more of the followingone or more of the following

palpation of a pulsepalpation of a pulse auscultation of heart soundsauscultation of heart sounds pulse oximetrypulse oximetry

CVP and arterial blood pressureCVP and arterial blood pressure

2.3 Temperature monitor2.3 Temperature monitor

when clinically significant changes when clinically significant changes in body temperature are intended, in body temperature are intended, anticipated, or suspectedanticipated, or suspected

Handoffs Handoffs Periodic breaks should be given to the Periodic breaks should be given to the

primary individuals providing anestheprimary individuals providing anesthesia. sia.

The following information should be cThe following information should be clearly presented learly presented

a. Prior clinical detailsa. Prior clinical details The patient's diagnosis, surgery, allergThe patient's diagnosis, surgery, allerg

ies, past medical and surgical history, ies, past medical and surgical history, relevant medications, and any pertinerelevant medications, and any pertinent normal or abnormal laboratory valunt normal or abnormal laboratory values or studies.es or studies.

b. Intraoperative managemeb. Intraoperative managementnt

Status of surgery, airway assessment and Status of surgery, airway assessment and management techniques, anesthetic plan management techniques, anesthetic plan and current status, current vital signs witand current status, current vital signs with an explanation for any apparent abnorh an explanation for any apparent abnormalities or trends, intravenous access anmalities or trends, intravenous access and monitoring, blood loss and volume statd monitoring, blood loss and volume status assessment, anticipated need for additus assessment, anticipated need for additional medications (e.g., narcotics, muscle ional medications (e.g., narcotics, muscle relaxation or reversal, antiemetics), relaxation or reversal, antiemetics),

Guidelines for action after an Guidelines for action after an adverse anesthesia eventadverse anesthesia event

The anesthesiologistThe anesthesiologist involved in an adverse event sh involved in an adverse event should do the following:ould do the following:

a. a. Provide for continuing care of the patient.Provide for continuing care of the patient. b. b. Notify the anesthesia operating room administratNotify the anesthesia operating room administrat

or as soon as possible. If a resident or certified regisor as soon as possible. If a resident or certified registered nurse anesthetist was involved in the event, tered nurse anesthetist was involved in the event, (s)he should notify the attending staff.(s)he should notify the attending staff.

c.c. Not discard supplies or tamper with equipment. Not discard supplies or tamper with equipment. d.d. Document events in the patient record (including Document events in the patient record (including

the serial number of the anesthesia machine).the serial number of the anesthesia machine). e.e. Not alter the record. Not alter the record. f.f. Stay involved with the follow-up care. Stay involved with the follow-up care. g. g. Contact consultants as needed.Contact consultants as needed. h. h. Submit a follow-up report to the department qualSubmit a follow-up report to the department qual

ity assurance committee.ity assurance committee. i.i. Document continuing care in the patient's record. Document continuing care in the patient's record.

The objectivesThe objectives are to limit patient inj are to limit patient injury from a specific adverse event assocury from a specific adverse event associated with anesthesia and to ensure thaiated with anesthesia and to ensure that the causes of the event are identified t the causes of the event are identified so that a recurrence can be prevented. so that a recurrence can be prevented.