Anesthesia complications: avoidance, recognition, and management (original) (raw)

Human error and latent risk in incidents in anaesthesia in New Zealand

Research has shown that human error in anaesthesia is a major contributor to critical incident in anaesthesia, what is unclear is how this occurs and what impact these incidents have on patients. The purpose of this thesis was to examine human error in anaesthesia using Reason’s (1990) framework of error and Swiss Cheese Model to identify the stages of anaesthesia in which errors occur, the frequency and severity of those errors, and the role of fatigue, stress, and usability in human error in anaesthesia. A two stage process was used to collect information on human error in critical incident. The first stage consisted of a task analysis and Flanagan’s (1954) critical incident analysis which allowed for the collection of information on the anaesthetic process, this information led to suggestions for a questionnaire to be used to collect data which could be quantitatively analyzed. In the second stage, a questionnaire was constructed and taken online by participants sent invitations from their respective District Health Board in New Zealand. A small sample size of data was acquired (n=12 responses) of which 8 were complete and used. Results were analyzed by a critical incident analysis. Human error was found to occur during all stages of anaesthesia with induction representing the most incidents and emergence the least. Incidents involving human error were found to be rare, occurring between once per yearly quarter to a few times per lifetime. Most incidents were found to be near misses, and almost a quarter of incidents were found to be of harm, of these only one was judged to be of moderate harm. Fatigue and stress were found to be associated with half of incidents, and equipment design was found to only be associated with a few incidents. This investigation is effective in highlighting examples of modern critical incidents of anaesthesia. These results indicate that fatigue and stress possibly play large roles in contributing to human error in anaesthesia and may be good areas for future research.

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting

British Journal of Anaesthesia, 2006

Background. This study aimed to explore how critical and acceptable practice are defined in anaesthesia and how this influences the discussion and reporting of adverse incidents. Method. We conducted workplace observations of, and interviews with, anaesthetists and anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively for adverse events in anaesthetic process witnessed. We also observed departmental audit meetings and analysed meeting minutes and report forms. Results. The educational value of discussing events was well-recognized; 28 events were discussed at departmental meetings, of which 5 (18%) were presented as 'critical incidents'. However, only one incident was reported formally. Our observations of anaesthetic practice revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were acknowledged as offering the potential to improve safety, although some were direct violations of 'acceptable' practice. Formal reporting appears to be constrained by changing boundaries of what might be considered 'critical', by concerns of loss of control over formally reported incidents and by the perception that reporting schemes outside anaesthesia have purposes other than education. Conclusions. Despite clear official definitions of criticality in anaesthesia, there is ambiguity in how these are applied in practice. Many educationally useful events fall outside critical incident reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but the reluctance to adopt a more explicit 'systems approach' to adverse events may impede further gains in patient safety in anaesthesia.

Critical incidents in anaesthesia: medicolegal and other aspects

Canadian Journal of Anaesthesia, 1991

The title of the Tenth Annual Anaesthetic Symposium of the Department of Anaesthesia, Foothills Hospital at the University of Calgary was "Critical incidents in anaesthesia: medico-legal and other aspects." The purpose of the symposium was to review the latest in the field of human factors implicated in the genesis of critical incidents. Similarities to accidents in aviation were identified and the medico-legal consequences were explored. Dr. Rob Lee began by describing the success of the aviation industry in developing a high standard of safety. He emphasized the importance of investigation of accidents, the development of a computerized database , and the relevance of the study of human factors in both aviation and anaesthesia. Dr. Jeffery Cooper followed with a description of methods of measuring untoward outcome in anaesthesia. He indicated the need to examine various types of adverse events but indicated that the subject studied would depend on the particular anaesthetic "culture." Dr. Jan Davies reviewed the theory of riskmanagement policies as applied to unanticipated adverse events, comparing American and Canadian aspects. She then described the particular system used at Foothills Hospital and emphasized the importance of a process for "emotional debriefing." Dr. J. N. Armstrong outlined the system for investigation of anaesthetic accidents which he and Doctors Davies and Lee have developed. He drew the analogy between the study of accidents in aviation and anaesthesia and indicated the trend to examine factors

Drug Administration Errors in Anesthesia : A Review

2004

Drug administration errors have been an increasing focus of concern in anesthesiology. These errors usually pertain to the type of drug administered, the drug dosage, the rate of administration or the site of administration. Past studies have attempted to identify and understand the underlying etiology of these common forms of errors, so as to avert its often serious and sometimes fatal consequences. These studies have focused on errors relating to the administrator's theoretical knowledge, clinical experience, individual technique and other such related factors. This growing body of research has proven invaluable, not only by addressing the preventability of drug errors by clinicians, but also in leading constructive efforts to minimize their repeated occurrence. This article attempts to highlight the current understanding of drug administration error in clinical anesthesia and discusses the risk management techniques that may be of value in dealing with this problem.

A prospective survey of anaesthetic critical events in a teaching hospital

Anaesthesia and intensive care, 1989

A survey of anaesthetic critical events based on voluntary anonymous reports was undertaken over a two and a half year period within a teaching hospital Department of Anaesthesia. At the end of the survey 167 reports were analysed. Human error was a contributing factor in 82% of events. Inadequate preoperative patient assessment or preparation, problems in the area of human/equipment interface and various stress factors for the anaesthetist featured significantly in the survey. The method enables the collection of objective data on factors contributing to anaesthetic and surgical risk and the formulation and evaluation of potential corrective strategies. It also facilitates harmonious peer review via individual and group feedback activities. The adoption of such a survey on a wider scale is seen as a valuable part of quality assurance in the continuing attempt to increase patient safety.

Why do Anesthesiologists Drug Administration Errors?

SOJ Anesthesiology & Pain Management

Medication error represents a particular challenge for the patient safety in tertiary care. Anesthesiologists should attempt against errors because they represents the unique medical specialty that administrate the drug without another professional conference, easily acting as vectors of adverse events during anesthesia [1]. Some factors expose more than others the susceptibility to undesirable events. This review has the purpose to define the main characteristics of drug administration errors in anesthesia practice. Mesh terms "medication errors", "anesthesia" and "anesthesiologists" were combined during the search for studies used in this review. Anesthesiologists errs during the whole perioperative period, but most cases tend to happen in the morning, at the beginning of anesthesia, with no harm, by in-training providers in all types of surgeries and patients. Errors as incorrect dose and substitution due to distraction and fatigue are more common. Some routines should be incorporated to the experience of the anesthesiologist to facilitate the correct practice.

Medication errors in anesthesia: unacceptable or unavoidable?

Brazilian Journal of Anesthesiology (English Edition), 2017

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame-game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Quality and patient safety in anesthesia service: Thai survey

Asian Biomedicine, 2010

Background: The Royal College of Anesthesiologists of Thailand (RCAT) performed large-scale epidemiologic study of anesthesia-related complications and national incidents study in 2004 and 2007, respectively. Objectives: Evaluate the anesthesia service in Thailand with regard to status of quality and patient safety. Material and methods: A pre-planned structured questionnaire regarding demographic, administrative, preanesthetic, intraoperative postanesthetic variables and complications were requested to be filled in by nurse anesthetists attending the refresher course lecture of RCAT in February 2008. Descriptive statistics was used. Results: Three hundred fifty questionnaires were given and 341 respondents (97%) returned the questionnaires. Most of the respondents (90%) worked in government section. Thirty percent of respondents practiced in hospital without medical doctor anesthesiologist and 58% of nurse anesthetists worked in hospitals that have been accredited. Forty-six percent of respondents reported unavailability of a 24-hour recovery room. The questionnaires revealed of inadequacy of anesthesia personnel (64%), inadequate supervision during emergency condition (53%), inadequacy of patient information regarding anesthesia (57-69%), and low opportunity for patient to choose choice of anesthesia (19%). The commonly used monitoring were pulse oximeter (92% of respondents) and electrocardiography (63%). One-third (32%) of respondents had to provide of anesthesia for patients with insufficient NPO (non per oral) time. Common problems that the respondents experienced were miscommunication (49%), intraoperative cardiac arrest during the past year (35%), error related to infusion pump (24%) and medication error (8%). Fifty-five percent of respondents had to monitor at least one patient per month receiving spinal anesthesia. Conclusion: Suggested strategies for quality and patient safety improvement in anesthesia service are increasing personnel, increasing 24-hour recovery room, improvement of supervision, improvement of communication, compliance to guidelines and improvement of nurse anesthetist's training regarding monitoring patient receiving spinal anesthesia and cardiopulmonary resuscitation.