Patient Safety

Educational Objectives

The goal of this program is to improve anesthesia patient safety. After hearing and assimilating this program, the cli­nician will be better able to:

1.   Describe common anesthetic medication errors.

2.   List the likely contributing factors resulting in anesthetic medication errors.

3.   Provide recommendations to minimize anesthetic medication errors.

4.   Consider how culture change can be brought about in health care.

5.   Evaluate the roles of perception, assumption, and communication in medical errors.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning commit­tee members to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning commit­tee reported nothing to disclose.

Acknowledgments

Dr. Kuchta spoke in Los Angeles, CA, at Anesthesiology Update 2008, held November 15, 2008, and sponsored by the Office of Continuing Medical Education, David Geffen School of Medicine at the University of California, Los Angeles; Mr. Nance, in Orlando, FL, at the 23rd Annual Meeting of the American Society of Pediatric Otolaryngol­ogy, held May 2-4, 2008, and sponsored by the American Society of Pediatric Otolaryngology. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Anesthesia Patient Safety: It is Not What You Think it is

Kenneth F. Kuchta, MD, Associate Clinical Professor of Anesthesiology; Chair, Quality Assurance; and Chief, Vascular Anesthesiology, David Geffen School of Medicine at the University of California, Los Angeles

Introduction: recent push toward patient safety and reduction of errors can be traced to report published in 2000 by Institute of Medicine; in report, medical community castigated for dismal patient safety record and errors related to patient care; anesthesiology, however, singled out repeatedly for commendations throughout report; in one in­stance, anesthesiology complimented for gains made, which were described as being “very impressive” and having “come about through a variety of mechanisms, all resulting in a reduction of errors”; anesthesiology also noted for reducing anesthetic mortality rates from 2 per 10  000 anesthetics down to 1 per 200,000 to 300,000

Mechanisms to ensure correct delivery of drugs: recent studies indicate drugs not being delivered correctly; sev­eral studies indicate anesthesia medication error of 0.1% to 0.75% per anesthetic; study from New Zealand  — involved survey of >10,000 anesthetics; found error rate of 1 in 133 anesthetics; Seattle, WA  —  same methodology as New Zealand study; looked at >6000 patients; found essentially same error rate; anesthetic medication errors found in New Zealand study included incorrect dose, substitution, omission, repetition, insertion of different drug, or incorrect route; most likely contributing factors  —  failure to check, distraction and inattention, haste or pressure to proceed, communication problems, drug label problems, fatigue, unfamiliar workplace or equipment, changes in personnel, similarity of ampules, inexperience, and inadequate knowledge; Canadian survey  —  found 138 events among 687 forms returned; 85% of anesthesia providers responding admitted to committing ³1 anesthetic error during career; most errors did not result in major morbidity (only 1.4%), although 4 deaths reported; <50% of anes­thesia providers reported always reading label before administering drug; conclusion  —  anesthesia medication er­rors likely more prevalent than originally thought; few tend to be serious, but may be matter of chance; adverse outcome may be blocked by, eg, reading label, placing easy-to-read labels, consistently having same medication in drawer at correct dose

Anesthetic environment vs other environments: on ward  —  medication order written by physician, transcribed by clerk, sent to pharmacy to be dispensed, sent back to floor, then administered by nurse; error (especially if it occurs early on) may be detected by many people; in anesthesia  —  procedure condensed to one person; anesthesia pro­vider prescribes, dispenses, and administers medication; often no one checking to potentially catch error; however, small number of drugs available in usual location at all times (creates comfortable, relaxing environment); confir­mation bias error occurs because oftentimes in familiar environment, humans tend to perceive confirming evidence more readily than nonconfirming evidence; frequently occurs in operating room (OR)

Minimizing errors: read label (failures may be due to fatigue, distractions, not reading label carefully); establish other mechanisms or barriers to detect potential errors; improve legibility of labels; place labels on every syringe; improve organization of workspace (eg, bar coding may provide backup to catch errors due to human frailty); nec­essary to have more error reporting in future; gather information about near misses; make drug safety officer part of anesthesia department; study drugs with similar packaging and presentations (note beforehand which drugs most likely to be used); use prefilled syringes (filled via linear preparation method; labeled in repetitive and consistent manner across preparation system); create opportunity for another person to check and document “fail-safe” mech­anisms within system (in environment free from distractions and pressures that occur frequently in OR); color cod­ing (practice relatively common among anesthesia providers but not favored by pharmacy profession)

Anesthesia group’s experience: developed system of rules and devices for organizing anesthesia workspaces; in­volved computer and bar code reader; allowed for cross-check of drug administration; also used to generate anes­thetic record

Medications (bolus or infusion): identified by preprinted labels (large clear font; included class and name of drug; color coded; bar code on label); labels preattached to prefilled syringes and vials (flags attached by licensed phar­maceutical manufacturer; label does not obscure original placed on vial by manufacturer; intention that user would open vial and transfer contents and label to syringe); option to preprint customizable labels on color laser printer; before administering drug, anesthesia provider expected to read label, then scan bar code label into com­puter system; computer would then announce name of drug, display name and class of drug on computer screen along with color coding related to drug, and suggest dose to be given (could be accepted or modified in com­puter); labeling based on important information first (eg, antagonist, opioid vs opioid antagonist)

Organization of workspace: mandated that no syringes or ampules be discarded (active tray in front; used tray to­ward rear; suggested drugs be placed in order of intended delivery); other tray included emergency drugs that might be needed; drawers on anesthetic cart also order-organized (first drawer commonly used drugs, placed in order drugs normally given; second drawer included less common and presumably more dangerous drugs [kept segregated from routinely-given drugs])

Problems with bar coding: some resistance from clinicians; on other hand,  some clinicians overreliant on system (physician would not visually check drug); in some instances, bar code could not be scanned; also, some diffi­culty scanning patient identification; computers on wheels (COWS) oftentimes could not fit into room (could not get close to patient to scan bar code), or necessary wireless connection unavailable; bypass measures imple­mented by nurses mostly violated intended principles of bar code scanning

Color coding: examples of widespread implementation in United States include black cap on concentrated potas­sium chloride (KCl) solutions and colored caps on drugs given to ophthalmology patients for use at home; color coding on anesthesia carts advocated by American Society of Anesthesiologists (standard from American Soci­ety for Testing and Materials); color coding based on class of medications (eg, narcotics blue, induction agents yellow, reversal or antagonist agents predominantly have striped label); arguments against color coding  —  related to system being used for large number of drugs across medical industry; distinguishing among colors dif­ficult unless next to each other; colors may fade; may not be able to produce exact color with every label batch; errors may occur if coding not applied consistently across industry; health care professionals may be unable to remember large variety of color codes; in anesthesiology, concerns about possibility of intraclass errors, color-blind anesthesia provider, or false sense of security (encourages not reading label); counter arguments  —  should only be used as backup or aid, not as way to definitively identify particular drug; can be used to quickly identify drugs of particular class; provides additional feedback and can help correct medication errors

Aviation Safety: A Practical Paradigm for Improving Surgery

John J. Nance, JD, Founding Member, the National Patient Safety Foundation of the American Medical Associ­ation; Commercial Pilot; Aviation Consultant, ABC World News and Good Morning America, Tacoma, WA

Introduction: OR closely parallels aviation experience; in aviation arena, accidents from mechanical causes mini­mized to almost zero

Professional culture: major issue; health care not focused on individual or individual’s position in human system as imperfect; cultural change in patient safety and quality takes 15 to 25 yr; previously, highly trained and highly motivated professional expected to be omnipotent, infallible, and without need for advice; present definition of leadership involves how well leader extracts, orchestrates, or utilizes available human talent

Dead man’s throttle principle:  example  —  pilot narrowly avoids accident; copilot saw but did not point out to pilot that he was approaching wrong runway; cultural change required in medicine  —   team members must be empow­ered to help catch errors made by individuals; team then able accomplish tasks unattainable as individuals; when building team, consider that person may not know how he or she comes across; people not honest with them­selves about how they are perceived and about limitations as humans; “every system is perfectly designed to get the results it consistently achieves”; must rewire essence of system and reevaluate all aspects of it; in medicine as in aviation, never one single cause but multiplicity of causes; normalization of deviancy  —creeping change in how things accomplished not caught in time to get back on track; assumption should always be that things can go wrong

How failure occurs: perception, assumption, and communication (one or more involved in all medical errors); indi­viduals mistakenly assume they are able to perceive things exactly right; in team environment, expectation that misperception can occur enables prevention of errors; 12.5% rule in communication  —12.5% of time, people who understand each other and speak same language misunderstand communication; expectation that physician always right major problem; another problem momentum of how things done (“this is the way we have always done it”); culture change means understanding fallibility as human beings; team not just collection of strong leader and good followers, but people who operate collegially, respect each other, and care about relationships; previously, attempt made to dehumanize systems; team members should check on each other as colleagues (creates level of perfection not achievable by individual by him- or herself); example of fatal airliner collision in which poor communication involved; example in which collision averted because junior officer warned pilot about danger

Suggested Reading

Donahue M et al: Medication administration process assessment: applying lessons learned from commercial avia­tion. J Nurs Adm 39:77, 2009; Fuller FW: The aviation paradigm and surgical education. J Am Coll Surg 202:200; author reply 200, 2006; Grogan EL et al: The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 199:843, 2004; Kohn LT: Organizing and managing care in a changing health sys­tem. Health Serv Res 35:37, 2000; Muller M: Safety lessons taken from the airlines. Br J Surg 91:393, 2004; Nance JJ. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare Press; 2008. Stabile M et al: Medication administration in anesthesia: time for a paradigm shift. Anesth Patient Safety Foundation Newsletter 22, Fall, 2007; Stolberg SG: Do no harm: breaking down medicine’s culture of silence. NY Times Dec 5, 1999; Webster CS et al: The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 29:494, 2001.