ANESTHESIA RISK

• Quality improvement (QI) programs are enhanced by risk management programs because they help to minimize liability exposure and maximize quality of patient care.
  • Risk management programs broadly reduce the organization’s liability exposure, including professional malpractice liability, contracts and employee and public safety. Key factors include:
    • Provider vigilance
    • Adequate monitoring
    • Up-to-date knowledge
    • Adequate systems that promote effective communication.
  • Perioperative surgical checklists are a key example of risk management.
  • QI program’s main goal is to continuously maintain and improve patient care quality.

Dental or denture damage is the most common injury leading to anesthesia malpractice claims.

QUALITY OF CARE

• Three components
  • Structure– setting where the care is provided
  • Process– sequence and coordination of patient care activities
  • Outcome– changes to the patient’s health status after medical care

• Critical incident– occurrences that caused (or can cause- i.e. near miss) injury if not corrected in a timely manner.

• Sentinel event– high-severity critical incidents that are unexpected occurrences involving death or serious injury and can indicate a serious internal problem.

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 84-86

Anesthesia Patient Safety Foundation (APSF) was founded in 1985 with the purpose “that no patient shall be harmed by anesthesia.”

The Joint Commission (TJC) is an independent nonprofit organization that sets standards for and accredits hospitals and other healthcare facilities. TJC was formerly known as JCAHO, or the Joint Commission on Accreditation of Healthcare Organizations.

• Participation is voluntary but is required in many states to receive Medicare and Medicaid reimbursement.
• A hospital must adopt a method for systematically assessing and improving important functions and processes of care and their outcomes in a cyclical fashion.
• TJC outlines National Patient Safety Goals annually.
  • ID patient correctly.
  • Improve staff communication.
  • Use medicines safely.
  • Use alarms safely.
  • Prevent infection.
  • ID patient safety risks.
  • Prevent mistakes in surgery.
• • Requires all sentinel events to undergo a timely systematic analysis and plan for corrective action.

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 37-41, 8

• An emancipated minor is one who, for the purposes of the law, is not a minor despite his/her being younger than the usual age of majority.

• Hazardous electrical shock can occur during surgery because of equipment use. They can be considered microshock or macroshock.
  • Microshock- small current flows that can become physiologically disruptive. The tissues are not usually injured but the flow can induce v-fib or other dysrhythmias. 100 µA can cause v-fib.
  • Macroshock- large electrical current flows that lead to thermal injury because the energy puts off heat. 100-300 mA (0.1-0.3 A) can cause v-fib but breathing remains intact.

• Most common OR fires are when there is an open oxygen source (not intubated or LMA) and an upper thorax surgery with cautery (like port placements, temporal artery biopsy).
• Three prevalent airway fire surgeries are:
  • Laser surgery
  • Tracheostomy
  • Tonsillectomy

The most common airway fire is due to laser surgery.

• • The mechanism for a laser-induced ETT fire is that the heat-generating laser beam contacts the ETT or the ETT is ignited by adjacent flaming tissue. The fire looks like a blowtorch.
    • Immediately remove ETT from the patient, stop the flow of gases, remove any other flammable materials from the airway, and pour saline into the airway.
  • Ways to guard against laser-induced airway fires
    • Intermittent mask ventilation and apnea
    • Low-frequency jet ventilation
    • Pulse-lasing
    • Reduce oxygen
    • Avoid lasering adipose and charred tissue
  • For every 10% increment of FiO₂ above 60%, the risk of fire increases by 2.3x.
  • Continuous use of a laser for longer than 5 seconds increased the risk by 72x.
  • The use of a laser on charred tissue increased the risk of fire by 98x.

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 92-119

American National Standards Institute (ANSI) Committee Z79 was sponsored until 1983. Now the American Society for Testing and Materials (ASTM) is recognized. The ASTM establishes voluntary goas that may become accepted as national standards for the safety of anesthesia equipment.

• Z79 or IT (implantation tested)- tracheal tubes of nontoxic plastic
• Anesthesia machine knobs
• PISS
• DISS
•  

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 10-11

National Institute for Occupational Safety and Health (NIOSH)

• Sets limits for waste anesthetic gas exposure

Occupational Safety and Health Administration (OSHA)

• Along with the EPA have published ionizing radiation exposure limits
• Noise reduction
•  

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 54-57

Food and Drug Administration (FDA)

• Improved electrical monitoring safety

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 105-106

Accreditation Association for Ambulatory Health Care (AAAHC)

• The first accrediting body for office-based anesthesia (OBA), which includes non-operating room anesthesia (NORA) and ambulatory anesthesia.
• They deal with the physical facility, patient care, governance, risk management, safety, infection control, record keeping, and administration.

REFERENCE: Barash Clinical Anesthesia 9^th edition, pages 829-838