Patient Safety Guidelines for Anesthesia Care
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 for the anesthetic. Some patients testify that they do not recall their anesthesia provider discussing any risks. In the event of a malpractice allegation, your written record of the informed consent process can be a powerful ally. It is surprising that many anesthesia records omit this important notation. A short note relating to the discussion of possible risks (sore throat, dental injury, etc.), benefits, and alternatives should suffice. The note should also address any patient-specific risks.
You should explain in advance to patients who have consented to regional anesthesia about the possible need for general anesthesia. When a spinal is inadequate or a high block develops, there will not be time to gain a second consent from the patient.
Determine an informed consent procedure that you are comfortable with, and make sure to document in the record what you explain to the patient. 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 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 also named if a malpractice case results. State laws vary as to how much legal responsibility the anesthesia provider has for surgical procedures. 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. If multiple surgeons are performing multiple procedures, a time out should take place prior to each procedure.
Make such procedures a routine part of your preoperative checks.
As noted in our Anesthesia Closed Claims Study, damage to natural teeth or cosmetic dental work is the second most common allegation in anesthesia claims.1 In addition to dental damage from a traumatic intubation, damage can occur in the recovery room when patients bite down on rigid plastic oral airways or supraglottic airways.
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 along with any steps taken to protect the teeth.
Anesthesia records are, by necessity, abbreviated and concise. That leaves little room for legible, detailed descriptions of unusual events. If something out of the ordinary happens that requires more room for adequate documentation, a supplemental narrative can be useful as an addition to the anesthesia record. 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.” The care of the patient always comes first, but you should write the narrative 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 free text note about an event may still be appropriate.
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.
Remember that all lab and diagnostic 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 that was 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. The anesthesiologist 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 suggest specific 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. This helps avoid the appearance that you are acting against another physician’s advice.
Though the administration of anesthesia has become safer over the years, attention to detail will help keep our patients safe, control risks, and decrease liability.