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Articles  |   April 2018
A Case Report From the Anesthesia Incident Reporting System
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Articles   |   April 2018
A Case Report From the Anesthesia Incident Reporting System
ASA Monitor 4 2018, Vol.82, 44-46.
ASA Monitor 4 2018, Vol.82, 44-46.
Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to airs@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2018-4: Switcheroo
On an otherwise uneventful Tuesday there were 30 cases waiting to start at 0730. One case was a healthy 4-year-old male for a laparoscopic-assisted ureteral re-implantation. In the preoperative room next door, a 5-year-old male who was also otherwise healthy was being prepped for a ureteral stent placement. Both patients had the same attending anesthesiologist who was supervising two residents. The attending performed the preoperative evaluation on both patients.
At 0725, the 5-year-old patient who was scheduled to undergo stent placement was taken to the operating room setup for the ureteral reimplantation. As is customary, the attending surgeon was not present for anesthesia induction and last saw the patient in the preoperative room.
Just prior to the induction of anesthesia, the team performed a sign-in and reviewed the patient’s ID band against the electronic anesthesia record and the consent form. The error was discovered and the patient was immediately transported to the correct operating room.
Discussion
The World Health Organization (WHO) surgical safety checklist consists of three parts (Figure 1). The first, commonly known as the sign-in, is performed prior to the administration of any induction drugs. This check verifies the patient’s identity against the consent form and the medical record as well as serves as a pause to ensure the planned anesthetic is appropriate for the procedure. There are also checkpoints to make sure key anesthetic risks have been accounted for, such as difficult airway, allergies or a high probability of significant blood loss.
Figure 1:
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
Figure 1:
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
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The surgical timeout requires the presence of the surgeon and is performed prior to incision. This check again verifies identity, the consent form and incision location. This element of redundancy is designed to further reduce the risk of operating on the wrong patient or body part. This checkpoint also calls for discussion of critical events, imaging, antibiotic compliance and introduction of all team members. The third and final portion of the checklist is typically called the debriefing or sign-out and includes verifying that the instrument counts are correct and specimens are identified, and offers an opportunity for reflection and system-based improvement.
There is a paucity of data in the literature on adoption of the full checklist. However, there is excellent evidence that if all parts of this checklist are performed by an engaged surgical team, morbidity and mortality fall dramatically. Haynes et al. found a decrease in the rate of death from 1.5 percent to 0.8 percent, and inpatient complications dropped from 11 percent to 7 percent across eight hospitals in eight separate cities.1  de Vries et al. also evaluated the impact of a surgical safety checklist and found the number of complications per 100 patients dropped from 27.3 to 16.7 and the in-hospital mortality decreased from 1.5 percent to 0.8 percent.2 
Please take a moment and think about the magnitude of those results.
One would expect that the full checklist would be active at every hospital in the U.S.; however, we know that is not the case. Fourcade et al. noted a host of cultural factors that prevented the full checklist from being implemented across 18 cancer centers. Their results showed that the checklist was completely used about 61 percent of the time.3  Of note, use of the checklist was mandatory. At a couple of national meetings, the author has informally asked large groups of anesthesia providers if the checklist is completely adopted at their institution. Most places perform a surgical time out; however, many do not perform a sign-in or debriefing. This case is an example of where the sign-in stopped a potential “never” event cold. One may hypothesize that the surgical timeout would have caught the mistake, or the surgeon would have noticed that he or she did not recognize the patient; but hope is not a good strategy for preventing “never” events.
Our recommendation is to examine your organization, and if the checklist is not in use, ask why. There have been very few interventions in modern medicine with a potential result as great as this. If your hospital or health system is using an electronic health record (EHR) and an anesthesia information management system (AIMS), there is even the potential to add the patient’s photo to a checklist displayed electronically in the anesthetizing location. Figure 2 (page 45), “Anesthesia Sign In,” is an example of this functionality. The WHO has a detailed implementation manual that can assist you in improving your organization’s adoption of the checklist.4  As a small bonus, your improvement efforts are eligible for MOCA Part IV credit.
Figure 2:
Sample electronic anesthesia sign-in report
Sample electronic anesthesia sign-in report
Figure 2:
Sample electronic anesthesia sign-in report
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The AIRS committee is interested in hearing your stories where the checklist was particularly helpful or did not stop an error from reaching the patient. Please consider submitting an AIRS report at aqiairs.org.
References:
Haynes AB, Weiser TG, Berry WR ; for Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. [Article] [PubMed]
De Vries EN, Prins HA, Crolla RM ; for the SURPASS Collaborative Group. Effective of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):19281937. [Article]
Fourcade A, Blache JL, Grenier C, Bourgain JL, Minvielle E . Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf. 2012;21(3):191–197. [Article] [PubMed]
World Health Organization. Implementation manual WHO surgical safety checklist 2009: safe surgery saves lives. http://apps.who.int/irisbitstream/10665/44186/1/9789241598590_eng.pdf. Published 2009. Last accessed February 14, 2018.
Figure 1:
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
Figure 1:
The WHO Surgical Safety Checklist (available at http://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ )
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Figure 2:
Sample electronic anesthesia sign-in report
Sample electronic anesthesia sign-in report
Figure 2:
Sample electronic anesthesia sign-in report
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