Presentation Transcript

1. Connecticut State Society of Anesthesiologists Preventing OR Disasters Before They Happen Rafael Ortega, MD Professor of Anesthesiology Boston University School of Medicine September 11, 2010 9:30 AM -10:30 AM
2. “One day, in his inimitable way, Vandam assigned Pierce the subject of “anesthesia accidents” to be given as a resident’s lecture. Years later, Dr Pierce, with others, founded one of the most influential organizations in anesthesiology, The Anesthesia Patient Safety Foundation.” Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask: safety revisited. Anesthesiology 1996;84(4):965- 75. Ortega RA: Leroy Vandam: An anesthesia journey. Journal of Clinical Anesthesia (2005) 17, 399–402
3. Accident?
4. Why do accidentshappen? Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible. Wagenaar and Groeneweg
5. Family Sues in Operating Room Fall “Matriarch suffered a fatal head injury Catherine O'Donnell, was a lifelong Dorchester resident… “ By Jonathan Saltzman Globe Staff January 29, 2008
6. Objectives To review conditions O.R. disasters have in common To present examples of O.R. disasters (or near disasters) To recommend strategies to minimize O.R. mishaps
7. Anesthesia Risk The rates of morbidity and mortality depend on the definitions. Data demonstrates that risk directly attributable to anesthesia has declined over time.
8. Liquid Oxygen Leak Birmingham, Alabama VA Hospital Schumacher SD et al. Bulk Liquid Oxygen Supply Failure. Anesthesiology. 2004;100:186-189.
9. It can happen to you too… Boston Medical Center June 15, 2006
10. It’s Everyone’s Business! Chest. 2010 Feb;137(2):443-9. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety Am J Surg. 2010 Jan;199(1):60-5. Factors compromising safety in surgery: stressful events in the operating room. J Health Serv Res Policy. 2010 Jan;15 Suppl 1:48-51. Errors in the operating theatre--how to spot and stop them. Surgeon. 2010 Apr;8(2):87-92. Epub 2010 Feb 18. Surgical fires, a clear and present danger. JtComm J Qual Patient Saf. 2010 Mar;36(3):133-42. Does teamwork improve performance in the operating room? A multilevel evaluation. Surgeon. 2010 Apr;8(2):93-95. Safe surgery, the human factors approach. QualSaf Health Care. 2010 Feb;19(1):69-73. Promoting patient safety through prospective risk identification: examples from peri-operative care
11. Potential Crises Anaphylaxis Transfusion Reactions Malignant Hyperthermia Difficult Airway Fires Electrical Safety Cardiac Arrest Etc. But what do they have in common?
12. Features in Common Critical incidents Reason’s Swiss Cheese Relatively Rare Training (and re-training) Required Communication Fixation Errors Reportable Litigation Prone
13. What is a “Critical Incident”? Term made famous by Cooper. Defined: occurrences that are “significant or pivotal, in causing undesirable consequences”. Also defined as: an event that led, or could have led to a problem. Critical Incidents provide opportunity to learn about factors that can be remedied. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.
14. BMC and Critical Incidents Root-Cause Analysis (Risk Management) On-line reporting 31-RISK Beeper (24 / 7 / 365) Physician Vice-President for Quality and Patient Safety
15. Recommendation Analyze all critical incidents (including the ones that could have led to a problem) Use a standardized approach to identify causes, system failures, and opportunities for improvement. Where was the hole in the Swiss cheese?
16. What is the Role of Simulation?
17. What is the Role of Simulation? Improving on Reality: Can Simulation Facilitate Practice Change? Anesthesiology. 112(4):775-776, April 2010. Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation Anesthesiology . 112(4):1041-1052, April 2010. Anesthesiology Residents' Performance of Pediatric Resuscitation during a SimulatedHyperkalemic Cardiac Arrest. Anesthesiology. 112(4):993-997, April 2010. Acquisition of Critical Intraoperative Event Management Skills in Novice Anesthesiology Residents by Using High-fidelity Simulation-based Training. Anesthesiology 112(1):202-211, January 2010. Simulation Training and Assessment: A More Efficient Method to Develop Expertise than Apprenticeship Anesthesiology. Anesthesiology.112(1):8-9, January 2010.
18. Expertise vs. Experience
19. Expertise vs. Experience Self-confidence Excellent communication skills Adaptability Risk tolerance Attention to what is relevant Ability to identify exceptions to the rules Effective performance under stress Ability to make decisions Quick reactions based on incomplete data Anesthesiology:Volume 107(5)November 2007pp 691-694 Experience ≠ Expertise: Can Simulation Be Used to Tell the Difference? Editorial - Weinger, Matthew B. M.D.
20. Simulation at BMC - Anesthesia
21. Simulation in Healthcare
22. Recommendation Simulate, conduct drills, review strategies. Although ideal, a simulation laboratory is not strictly necessary to engage in simulation.
23. Illustrative Examples Wrong Dose: Communication Error Missing Kidney: Communication Error Airway Management: Fixation Error Wrong Gas Administration Malignant Hyperthermia
24. Communication Error “eight thousand of heparin” vs. “a thousand of heparin”
25. Communication Error Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding. Control Room aboard USS Seawolf submarine. (courtesy of www.navy.mil)
26. Stairway of Communication Done action Understood X X X X Not said Not done Not understood Heard Not heard Said Meant Closing the loop Modified from Miller’s Anesthesia. Elsevier 2009
27. Recommendation Use Closed-Loop Communication whenever possible.
28. The Missing Kidney In December 1954, Dr. Murray performed the world's first successful kidney transplant between the identical Herrick twins at the Peter Bent Brigham Hospital.
29. “The Ether Screen”
30. Transparent Drapes
31. Transparent Drapes Transparent Ether Screens: The Road to New Transparency Ortega R, Gonzalez M, Lewis K ASA Newsletter , February, 2010
32. Transparent Drapes Transparent Ether Screens: The Road to New Transparency Ortega R, Gonzalez M, Lewis K ASA Newsletter , February, 2010
33. Why Communication Fails in the Operating Room J Firth-CozensQualSaf Health Care 2004;13:327 Team instability - different scrub nurses Team policies about communication - proper introductions Disallowing distractions - noise Redundancy - allows people time to communicate Sufficient resources - equipment Stress – what stress? Introverts Vs. Extroverts – many examples Professional language - way of maintaining power? Team meetings outside immediate task - enhancing rapport
34. BUMC Band
35. Losing the Airway 27-years-old male patient Fracture jaw Naso-tracheal intubation Class I visualization Difficult ventilation Equivocal capnogram Severe bronchospasm?
36. The Tube is in the Trachea! Leissner KB, Ortega RA, et. al. Kinking of an endotracheal tube within the trachea: a rare cause of endotracheal tube obstruction. Journal of Clinical Anesthesia (2007) 19, 75–81
37. ETT Foreign Body Anesthesia Machine Ascaris ETT Kinking ETT Defective Severe Bronchospasm Chest Rigidity Turbinate Avulsion
38. Fixation Errors Human errors (1/3 of error: FIXATION) > Equipment failures DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg. 1990 Jul;71(1):77-82.
39. "This and only this!" Accept possibility that first assumptions may be wrong Persistent failure to revise a diagnosis Rule out worst case scenario "Everything but this!" failure to commit to definitive treatment of major problem Artifacts are the last explanation for changes in critical values "Everything is OK!" Persistent belief that no problem is occurring Fixation Errors Types and Recommended Countermeasures Error Type Description Countermeasure (Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2007)
40. A 66-year-old woman admitted to SICU after CABG. History of severe hypertension on a nitroprusside drip. The surgeon had warned about a friable aorta. 125 100 75
41. 5 Minutes 150 125 100 75 She has severe hypertension…..
42. 10 Minutes 175 150 125 100 75 She is pain…..
43. 200 15 Minutes 175 150 125 100 75 She is anxious…..
44. 225 200 20 Minutes 175 150 125 100 75 Nitroprusside dose is insufficient…..
45. 225 200 >30 Minutes 175 150 125 100 75 Oh no!
46. Initial State Goal State A B 15 Cents C It costs 2 cents to open a link and 3 cents to close it again D Adapted from: E. Fioratou et al. No simple fix for fixation errors Anaesthesia, 2010, 65, pages 61–69
47. 2 cents to open a link x 3 = 6 3 cents to close a link x 3 = 9 Total = 15 3 97% 1 2 “Lateral Thinking”
48. Heuristics A rule of thumb, simplification, or educated guess that reduces or limits the search for solutions in domains that are difficult and poorly understood. Pattern Matching Machine if X (local signs of a problem exist) then it is probably Y (a particular condition to be managed) or if X (local signs) then do Y (a particular intervention).
49. Recommendation Be aware of fixation errors and strategies to prevent them.
50. Wrong Gas: a rare event
51. Incidents with Gases Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube.Eur J Anaesthesiol. 2000 Jul;17(7):456-8. Oxygen contamination of the nitrous oxide pipeline supply.Anaesth Intensive Care. 1998 Apr;26(2):207-9. Failure of operating room oxygen delivery due to a structural defect in the ceiling columnMasui. 2000 Oct;49(10):1165-8. Pollution of the medical air at a university hospital in the metropolitan Tokyo area. Journal of Clinical Anesthesia. 14(3):193-5, 2002. Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device. AnnalesFrancaises d Anesthesie et de Reanimation. 15(5):683-5, 1996. Contamination of the medical air supply with oxygen: a clinical engineering incident investigation. Journal of Clinical Engineering. 15(4):295-300, 1990. Medical air contamination with oxygen associated with the BEAR 1 and 2 ventilators. Critical Care Medicine. 16(4):362, 1988.
52. Fixation: Everything is OK Patient complaining of pain Free air the abdomen Cost center discrepancies
53. A Close Call
54. Good Idea
55. FDA MAUDE DATABASE
56. PROBLEMS WITH: Teamwork and Communication Design, Construction and Maintenance Equipment Standardization Drug Labeling, Purchasing, Stock Control, and Delivery Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia Providers PROBLEMS WITH: Distraction Momentary Inattention Forgetting Losing the Picture Preoccupation Fixation (Psychological Antecedents of Unsafe Acts) The Organization The Individual Adapted from: Reason: QualSaf Health Care 2005;14:56–61
57. Controllable Hard to Control PROBLEMS WITH: Teamwork and Communication Design, Construction and Maintenance Equipment Standardization Drug Labeling, Purchasing, Stock Control, and Delivery Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia Providers PROBLEMS WITH: Distraction Momentary Inattention Forgetting Losing the Picture Preoccupation Fixation (Psychological Antecedents of Unsafe Acts) what goes on in the head of the practitioner beyond a certain point—extremely difficult to control The Organization The Individual
58. The Swamp “Unsafe acts are like mosquitoes. They can be swatted or sprayed, but they still keep coming. The only effective remedy is to drain the swamps in which they breed.” Adapted from: Reason: QualSaf Health Care 2005;14:56–61
59. The Garden
60. Stages in the Development of an Organizational Accident Instigators (Swamp) Inheritors (Mosquitoes) OR Executive OR Worker Operating Room Defenses Errors Violations Management Decisions Organizational Processes Corporate Culture Error-Producing Conditions Violation-Producing Conditions Incident Accident Sequence begins with negative consequences of processes : decisions regarding planning, scheduling, forecasting, designing, specifying, communicating, regulating, maintaining, etc. Latent failures transmitted along organizational pathways to workplace creating local conditions that promote the commission of errors and violations: understaffing, fatigue, technical problems, high work load, poor communication, conflicting goals, inexperience, low morale, teamwork deficiencies, etc. Unsafe acts are likely to be committed, but only few penetrate the defenses to produce incidents. Adapted from: Reason: QualSaf Health Care 2005;14:56–61
61. Malignant Hyperthermia
62. Malignant Hyperthermia
63. Dantrolene Rosenberg H: Anesthesiology News March 2010
64. Malignant Hyperthermia Rosenberg H: Anesthesiology News March 2010
65. A. Line Infection Ortega R, Rengasamy SK, Lewis KP: Infection after radial artery catheterization. Anesth Analg 2002;95:780-7
66. Amyloidosis
67. Compartment Syndrome
68. Impalement of the Brain
69. Broken Needle in Aorta
70. Ventilator Failure 1 Ortega RA, Vrooman B, Hito r: Another Cause for Ventilator Failure. Anesthesiology. Anesthesiology. 104(6):1351, June 2006
71. Ventilator Failure 2 Ortega RA. Zambricki ER. Fresh gas decoupling valve failure precludes mechanical ventilation in a Draeger Fabius GS anesthesia machine. Anesthesia & Analgesia. 104(4):1000; 2007 Apr
72. Administrative Guidelines for Response to an Adverse Anesthesia EventJournal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Febwww.APSF.org Primary anesthetist concentrates on continuing patient care. Notify a physician responsible for supervision of anesthesia activities Sequester equipment Contact the hospital Risk Manager immediately Anesthesiologist and other individuals document relevant information After discussion with the incident supervisor, write on medical record relevant information about what happened and actions taken Complete and file incident report as soon as practical State only facts. Do not use judgmental terms Consult early and frequently with the surgeon. Immediately call other consultants who may help improve long term care
73. Avoid Fixation Simulate Summary