Patient Safety in Anesthesiology

Adverse anesthesia events can occur despite the sophisticated monitors in use. Most adverse events should not occur but do because alarms have been silenced or were silenced at the end of the prior case and not reactivated. (Be aware that some machines do not automatically reset the alarm.) Do not neglect pulse oximeter and CO2 alarms. The American Society of Anesthesiologists standards require that alarms be audible to the anesthesiologist or members of the anesthesia care team.1

A complete preanesthetic evaluation that includes the airway is essential to patient safety. Using a classification system, such as Mallampati, demonstrates that a thorough airway exam was performed.

The anesthesia-specific informed consent process includes engaging the patient in a discussion of the types of anesthesia or sedation that are available, the risks and benefits of each type, and any alternatives. Provide the patient with an opportunity to ask questions.

Even with the advent of airways that don’t require laryngoscopy, dental injuries remain the most frequently encountered adverse event in anesthesia. Performing and documenting a dental exam and including dental injury as an identified risk in your informed consent discussion may be effective in mitigating the exposure. This process can be especially important with patients who have had cosmetic dentistry procedures.

Many patients who have obstructive sleep apnea (OSA) have not yet been diagnosed. The use of a screening tool, such as the STOP-BANG Sleep Apnea Questionnaire, can be useful in identifying patients who may be at risk. It’s important to use pulse oximetry postoperatively if you suspect OSA. Also consider the use of regional analgesic techniques without opioids for the postoperative period.

Using warming techniques to maintain the patient’s body temperature appears to be a factor in reducing the risk of surgical infections, prolonged neuromuscular blockade, and cardiac events. It can also help decrease the duration of postanesthesia recovery and extubation time. Steps taken to maintain normothermia should be documented. One note: Use care in warming efforts, especially in patients who may be frail or have thin skin (such as the very young or the very old), as burns can occur easily and are a source of claims.

In cases with prolonged neuromuscular blockade, critical respiratory events continue to occur in the PACU due to inadequate reversal of the agents. Even with intermediate acting, nondepolarizing blockers, each patient should be objectively evaluated to see if adequate reversal has occurred. This is demonstrated when the train-of-four ratio is 0.7 or greater.2

Operating room fires occur about 600 times each year.3 Follow fire prevention guidelines by: (1) controlling the use of heat and ignition sources, including electrosurgical units, heated equipment, and lasers; (2) managing fuels, such as skin prepping solutions, ointments, and dry dressings; and (3) reducing oxidizers by minimizing oxygen concentrations and tented surgical draping. In the event an operating room fire occurs, appropriate equipment and supplies must be immediately available. The organization’s emergency plan should include practice drills with surgical, operating room, and anesthesia personnel so that all team members are familiar with their fire management roles.

 

References

  1. American Society of Anesthesiologists. Standards and Practice Parameters Committee. (2011, July 1). Standards and Guidelines. Available at: www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/standards-for-basic-anesthetic-monitoring.pdf.
  2. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part 1: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010 Jul;111(1):120-128.
  3. Hart S. Yajnik A, Ashford J, Springer R, Harvey S. Operating room fire safety. Ochsner Journal. 2011 Mar;11(1):37-42.

 

By Donald Wood, CRNA, CPHRM, Patient Safety Risk Manager II.  


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.

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