Patient Safety Guidelines for Anesthesia Care
Safe anesthesia practices are not limited to the time spent during a surgery or procedure. Safe anesthesia care begins with the preoperative assessment and continues through the postoperative period. To help you keep your patients safe and avoid liability risks, we highlight common oversights and offer suggestions for practice improvement.
Many anesthesia records include no evidence that the patient gave informed consent. Patients often testify that they do not recall their anesthesia provider discussing any risks. The frequent use of amnestics as premedication, given shortly after the preoperative interview, is one possible explanation. Often, there is no third-party witness to the interview, and the anesthesia provider will have only a written record of the informed consent process. What is surprising, however, is that many anesthesia records omit this important notation. Your documentation need not be extensive: “Discussed general anesthesia risks with patient, including sore throat, dental injury, pneumonia, and death.”
No patient entering surgery wants to hear about possible death. You can, however, phrase the risks in a reassuring light: “Anesthesia is becoming safer all the time. Death during surgery is extremely uncommon these days, but I need to mention this as a rare complication of anesthesia.” That advisory is important from a malpractice standpoint. Patients who have consented to the remote possibility of death will have difficulty arguing that they never would have had anesthesia had they known a dental crown could be loosened.
You should explain in advance to patients who have consented to regional anesthesia the possible need for general anesthesia. If a spinal wears off intraoperatively or a high block develops, you will not be able to gain a second consent from the patient—and attorneys pay extraordinary attention to the informed consent process.
Determine an informed consent procedure that you are comfortable with, and make sure to document in the record what you explain to the patient. For greater liability protection, the anesthesia provider is encouraged to use an anesthesia-specific informed consent document. This memorializes patient consent separately rather than relying on a surgical consent form for addressing anesthesia issues. Combining the anesthesia consent with the surgical consent inappropriately diminishes the importance and significance of the administration of anesthesia.
When a surgeon operates on the wrong limb or performs a procedure not listed in the surgical consent, the anesthesia provider is usually named if a malpractice case results. State laws vary as to how much legal responsibility the anesthesia provider has for surgical procedures. Still, prevention is the best defense against a malpractice claim. Active involvement in the time-out procedure to verify a patient’s identity and to check the surgical consent for the correct procedure, correct side, correct site, and correct position takes less than a minute. A time out should also occur prior to the performance of an anesthetic block, and if multiple surgeons are performing multiple procedures, a time out should take place prior to each procedure.
Taking that time can save you, the surgeon, the nurses, and the hospital a considerable amount of anguish should a discrepancy arise. Make such procedures a routine part of your preoperative checks.
Damage to natural teeth or cosmetic dental work causes many anesthesia claims. In a review of The Doctors Company closed claim data for anesthesia, dental damage is the most frequent allegation. In addition to dental damage from a traumatic intubation, damage often occurs in the recovery room when patients bite down on rigid plastic oral airways.
Dental damage claims are usually settled by paying for the dental repair work. The cost escalates markedly, however, when either the patient or the provider becomes angry. As a rule, dental injury should be mentioned as a possible risk to all patients who have consented to general anesthesia. The preanesthetic evaluation should include thorough documentation of dental condition.
As with any indication of patient dissatisfaction, notify The Doctors Company if a patient has complained of possible dental injury.
Anesthesia records are, by necessity, abbreviated and concise. That leaves little room for detailed descriptions of unusual events. If something out of the ordinary happens (e.g., anaphylaxis, respiratory arrest, cardiac arrest), it is extremely useful to have a separate narrative that details the sequence of events, documents the time as closely as possible, and records the treatment rendered. If you are ever called upon to defend your care and treatment, it is better to have a record that reads “narrow complex bradyarrhythmia unresponsive to atropine” than one that says “patient coded, resuscitation performed.” Care of the patient always comes first, and no one expects you to fill out the record during an emergency situation, but you should write the narrative, with times and dates, while events are fresh in your mind.
If you are using an electronic Anesthesia Information Management System (AIMS), the automated real-time input of vital sign data may increase the accuracy of the anesthesia record. However, a handwritten note (“free text”) about an event may still be appropriate.
When an untoward event occurs, there is a tendency to want to make sure your anesthesia record is perfect. Do not make alterations after the fact. One anesthesiologist, after a patient’s respiratory arrest, decided to rewrite his anesthesia record, so he threw the first copy into the trash. When the case became a malpractice claim, the first copy was produced by the surgery center, thereby casting doubt on the anesthesiologist’s veracity and motives. Similarly, it is unwise to chart ahead or write notes in advance. Subsequent events may not correspond to what you have written.
In the rush to start a procedure, the anesthesia provider may not wait for lab values to return. You must not neglect pending laboratory tests. For nonemergencies, all preoperative labs that could potentially change your course of action should be available and read.
One anesthesiologist placed a patient under general anesthesia for an arteriovenous shunt placement procedure before a potassium level of eight was reported to the operating room. The patient suffered an arrest before the procedure could be terminated.
Obtaining the EKG result is also important. An EKG may not be available to you if it is performed at an outside office that is not open in time for a procedure scheduled at 7:30AM. It is wise, however, to secure at least a verbal report from a physician who has seen the EKG and believes it presents no problem. Even if you would not have ordered an EKG on an otherwise healthy patient, if another doctor has ordered one, you should consider the possibility that it might return reading “lateral ischemia, severe left ventricular strain.” Would that change the anesthetic technique you would use?
Remember that all lab tests and results will be on the patient’s chart when it is reviewed in a malpractice case. You may appear negligent if you have not reviewed all of the information potentially available to you. The argument that “my surgeon was in a hurry to start the procedure” will not be well received.
A similar caution applies to outside consultations and surgical clearances. If the surgeon states that a patient has been cleared by another physician, you should either review a copy of the dictated consult or speak to the physician involved. There may be medical information in the consult that is not available elsewhere in the chart. The consultant may have had access to old records or to history from the patient’s relatives that is not available to you. Some consultants may write things like “cleared for local standby only” or “needs Swan-Ganz catheter monitoring.” You should address such issues before starting the procedure. If you do not agree with the suggestion, it is best to discuss it with the consulting physician and to document the discussion in a note: “I have discussed this procedure with Dr. Jones in detail, and he understands that this amputation cannot be done under local standby. He believes the patient is medically optimized for general anesthesia or spinal.” Such a note will avoid the appearance that you are acting against another physician’s advice.
Labor and Delivery
Informed consent always presents a special problem in labor and delivery. Often, the anesthesia provider meets the patient for the first time when the patient is in the throes of active labor. How can the patient reasonably be expected to understand the risks of labor epidurals in such a condition? Preferably, you should meet the patient earlier and discuss the anesthesia risks in more relaxed circumstances. Your remarks could begin: “I know you are not uncomfortable now, but you may be during your labor. I would like to introduce myself and to discuss what to expect if you decide on a labor epidural.” If such discussion is not possible, still mention the risks, however briefly, to the labor patient. Include her partner if present, and allow them to ask any questions they may have.
Patients often have misconceptions about epidurals or have heard alarming information about possible paralysis or spinal damage. While you should reassure them, avoid comments like “there is no chance of any permanent damage.”
Although rare, there have been cases where patients developed unusual neurological syndromes, including muscle weakness or autonomic dysfunction. When these cases are taken to court, the plaintiffs’ expert witnesses can often convincingly relate those problems to the epidurals. Such cases might require settlement—even without apparent negligence on the part of the anesthesia provider—if there is no evidence of informed consent.
If you are unable to obtain a written anesthesia-specific informed consent on admission, a brief informed consent discussion with a labor and delivery epidural patient could be: “Infrequently, patients get headaches from placement of the epidural. If you do, there are treatments available. Other uncommon complications are backache, neurologic damage, or death.”
Documentation is frequently less complete in labor and delivery records than in those from the operating room, but make no mistake—it is equally important. Pertinent information about the insertion of an epidural, the interspace level used, or the absence of paresthesias is often missing from charts reviewed in malpractice claims.
The Doctors Company frequently receives questions about the provision of anesthesia services during labor and delivery. How available does the anesthesia provider need to be? Whether there is a dedicated on-call anesthesia provider for labor and delivery or the same provider also covers the main operating room depends on hospital policies and community standards.
Regardless of your hospital’s coverage plan, be aware of the American College of Obstetricians and Gynecologists’ guideline declaring that there should be an incision time of 30 minutes or less for emergency cesarean sections. That means that once an obstetrician declares that a cesarean section is needed urgently for maternal or fetal well-being, the patient should be ready for an incision within 30 minutes. Anesthesia providers have been faulted in malpractice cases for failure to arrive within this time period. Many providers have the misconception that they cannot be sued for not being available if they have never met the patient. If you are responsible for covering labor and delivery and do not respond in a timely fashion, you may be held responsible for the delay of a cesarean section. The argument that the surgeon could have done the surgery under a local anesthetic may not relieve you of responsibility.
If the hospital allows a trial of labor after cesarean section (TOLAC)/vaginal birth after cesarean section (VBAC), anesthesia personnel must be immediately available. TOLAC/VBAC should be attempted only at facilities capable of emergency deliveries.
Wet taps resulting in postspinal headaches are an increasingly common cause of malpractice claims. Often, patients with such complaints are angry about not receiving appropriate care when they complain about postprocedure headaches. Patients who receive prompt treatment, such as IV fluid and blood patches, are less likely to sue.
Discuss the possibility of a wet tap with your patient before discharge if you think he or she may have unintentionally received one. Give the patient a phone number to contact you or another anesthesia provider should additional treatment be required.
Make sure your anesthesia department has a procedure for blood patching for postspinal headaches should your patient require treatment after leaving the hospital. Check to be sure that the on-call provider will take responsibility if you are unavailable. A patient who has to make multiple phone calls or who gets a large hospital bill for the blood patch is more likely to consider legal recourse. Most hospitals will provide space in labor and delivery or in the recovery room at no charge.
By Ann S. Lofsky, MD (deceased), Anesthesia Consultant and Board Member Emeritus; updated by Julie Brightwell, JD, RN, Director, Hospital and Facility Patient Safety.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.