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Preventing Operating Room Disasters Before They Happen

1 st Annual Ellison Pierce Symposium Positioning Your Anesthesia Practice for the Future. Preventing Operating Room Disasters Before They Happen. Rafael Ortega, MD Associate Professor of Anesthesiology. Boston University School of Medicine May 5, 2005. 9:30 AM – 10:00 AM. Objectives.

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Preventing Operating Room Disasters Before They Happen

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  1. 1st Annual Ellison Pierce Symposium Positioning Your Anesthesia Practice for the Future Preventing Operating Room DisastersBefore They Happen Rafael Ortega, MD Associate Professor of Anesthesiology Boston University School of Medicine May 5, 2005 9:30 AM – 10:00 AM

  2. Objectives • To review conditions O.R. disasters have in common • To recommend strategies to minimize O.R. mishaps • To present examples of O.R. disasters (or near disasters)

  3. Anesthesia Risk • The rates of morbidity and mortality depend on the definitions. • Data demonstrates that risk directly attributable to anesthesia has declined over time.

  4. Liquid Oxygen Leak Birmingham, Alabama VA Hospital Schumacher SD et al. Bulk Liquid Oxygen Supply Failure. Anesthesiology. 2004;100:186-189.

  5. It’s Everyone’s Business! Recognition, management, and prevention of specific operating room catastrophes Presented at the American College of Surgeons 89th Annual Clinical Congress, Chicago, IL, October 2003. Christopher R. McHenry MD, Ramon Berguer MD, FACS, Rafael A. Ortega MD Journal of the American College of Surgeons Volume 198, Issue 5 , May 2004, Pages 810-821

  6. Potential Crises • Anaphylaxis • Transfusion Reactions • Malignant Hyperthermia • Difficult Airway • Fires • Electrical Safety • Cardiac Arrest • Etc. But what do they have in common?

  7. Features in Common • Critical incidents • Reason’s Swiss Cheese • Relatively Rare • Training (and re-training) Required • Fixation Errors • Reportable • Litigation Prone • More…..

  8. …more preparation needed… Normal MP l Small jaw MP ll Small jaw Short neck MP lll Small jaw Short neck Obese Goiter MP lV

  9. Preparedness match risk waste match Complexity

  10. Successive Layers of Defenses Unsafe Acts Precondition for Unsafe Acts Unsafe Supervision Organizational Influences Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

  11. Aligned Holes Failed or Absent Defenses Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

  12. System Failure Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

  13. What is a “Critical Incident”? • Term made famous by Cooper. • Defined: occurrences that are “significant or pivotal, in causing undesirable consequences. • Also defined as: an event that led, or could have led to a problem. • Critical Incidents provide opportunity to learn about factors that can be remedied. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.

  14. What is the Role of Simulation? • Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992: 63: 763-770 • Holzman RS et al:. Anesthesia crisis resource management: real-life simulation training in operating room crises. Journal of Clinical Anesthesia. 7(8):675-87, 1995: >50% felt it should be taken once every 12 months • Ziv A et al: Simulation based medical education: anopportunity to learn from errors. Medical Teacher. 27(3):193-9, 2005 May. • Berkenstadt H et al: The feasibility of sharing simulation-basedevaluationscenarios in anesthesiology. Anesthesia & Analgesia. 101(4):1068-74, 2005 Oct. • Ziv A et al: Simulation-Based medical education:an ethical imperative. Academic Medicine. 78(8):783-788, 2003.

  15. What is the Role of Simulation? 21 September 2005. JetBlue Flight 292

  16. Illustrative Examples • Airway Management – Fixation Error • Wrong Gas Administration • Anaphylaxis • Malignant Hyperthermia • Fires

  17. Losing the Airway • 27-years-old male patient • Fracture jaw • Naso-tracheal intubation • Class I visualization • Difficult ventilation • Equivocal capnogram • Severe bronchospasm?

  18. Fixation Errors Human errors (1/3 of error: FIXATION) > Equipment failures DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg. 1990 Jul;71(1):77-82.

  19. Fixation Errors Types and Countermeasures Error Type Description Countermeasure "This and only this!" Accept possibility that first assumptions may be wrong Persistent failure to revise a diagnosis Rule out worst case scenario "Everything but this!" failure to commit to definitive treatment of major problem Artifacts are the last explanation for changes in critical values "Everything is OK!" Persistent belief that no problem is occurring Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2005)

  20. Circular No. 60-22. Federal Aviation Administration Washington, DC

  21. Hazardous Attitudes and their Antidotes Attitude Example Antidote ANTI-AUTHORITY Follow the rules. They are usually right "Don't tell me what to do. The policies are for someone else." Not so fast. Think first. IMPULSIVITY "Do something quickly-anything!" “It could happen to me. Routine cases develop problems." INVULNERABILITY "It won't happen to me. It's just a routine case." Taking chances is foolish. Plan for failure MACHO "I'll show you I can do it. I intubate anyone’s trachea." “I'm not helpless. I can make a difference” RESIGNATION "What's the use? It's out of my hands."

  22. Wrong Gas: a rare event

  23. Wrong Gas: a rare event Coolers/Dryers Compressors

  24. Wrong Gas: a rare event Backup System Tanks Valves

  25. Incidents with Gases Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube.Eur J Anaesthesiol. 2000 Jul;17(7):456-8. Oxygen contamination of the nitrous oxide pipeline supply.Anaesth Intensive Care. 1998 Apr;26(2):207-9. Failure of operating room oxygen delivery due to a structural defect in the ceiling columnMasui. 2000 Oct;49(10):1165-8. Pollution of the medical air at a university hospital in the metropolitan Tokyo area. Journal of Clinical Anesthesia. 14(3):193-5, 2002. Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device. Annales Francaises d Anesthesie et de Reanimation. 15(5):683-5, 1996. Contamination of the medical air supply with oxygen: a clinical engineering incident investigation. Journal of Clinical Engineering. 15(4):295-300, 1990. Medical air contamination with oxygen associated with the BEAR 1 and 2 ventilators. Critical Care Medicine. 16(4):362, 1988.

  26. Fixation: Everything is OK • Patient complaining of pain • Free air the abdomen • Cost center discrepancies

  27. Anaphylaxis • Forty-two anaesthetists in teams of two attended training sessions with a critical incident of anaphylactic shock in a full-scale simulator. • None of the teams made the correct diagnosis within 10 min and treatment according to the treatment sequence was not initiated. • Only 6/21 teams considered the right diagnosis only after hints from the instructor 15 min after the start of the incident. • Conclusion: Anaphylactic shock was difficult to diagnose and no structured plans were used for the treatment in the simulated incident in this study. Jacobsen J, Lindekaer AL, Ostergaard HT, et al. Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator. Acta Anaesthesiol Scand 2001 (Department of Anaesthesiology; Section of Simulation; Herlev Hospital; DK-2730 Herlev; Denmark)

  28. 3% 1% Muscle Relaxants Latex 3% Antibiotics 69% 4% Hypnotics 8% Colliods Opioids 12% Other Drugs Involved in Perioperative Anaphylaxis Data from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395

  29. Treatment of Perioperative Anaphylaxis from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395

  30. Treatment of Perioperative Anaphylaxis Modified from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395

  31. Malignant Hyperthermia

  32. Malignant Hyperthermia

  33. Dantrolene • 20mg/ampule • 60 cc’s of sterile water • Dose: 2.5mg/kg (1mg/lb) • 100kg patient = 10 ampules

  34. A. Line Infection Ortega R, Rengasamy SK, Lewis KP: Infection after radial artery catheterization. Anesth Analg 2002;95:780-7

  35. Amyloidosis

  36. Compartment Syndrome

  37. Impalement of the Brain

  38. Broken Needle in Aorta

  39. Ventilator Failure Ortega RA, Vrooman B, Hito r: Another Cause for Ventilator Failure. Anesthesiology. Accepted for publication Jan 2006

  40. Fire Ortega RA: A Rare Cause of Fire in the Operating Room. Anesthesiology. 89(6):1608, December 1998.

  41. Oxidizer Fire Triad Fuel Ignition Source The Fire Triad

  42. MAC EDITORIAL MAC Should Stand for Maximum Anesthesia Caution, Not Minimal Anesthesiology Care Hug CC: Anesthesiology: Volume 104(2) February 2006 pp 221-223

  43. Closed Claims Injury and Liability Associated with Monitored Anesthesia Care: A Closed Claims Analysis Bhananker SM, Posner KL, Cheney FW, Caplan RA et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

  44. Mechanism of Injury Bhananker SM et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

  45. Fires Bhananker SM et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

  46. MAC: Take Home Message • Least qualified anesthetist assigned • Diligence often less by anesthetist and surgeon • History of safety(Resting On Your Laurels) • Limited pre-anesthetic evaluation • Surgeons may explain MAC as: “a nap” • Competing goals: surgeon/anesthetist/patient • Head and neck procedures: conflict with airway • Antiseptic solutions disguise skin color changes • Head and trunk draping reduces respiration visibility

  47. MAC: Take Home Message • Monitor displays poor visibility • Audible monitor signals drowned out by music/noise • Impeded Auscultation of heart and lungs • Personnel inexperienced in resuscitation techniques • Oxygen delays Hgb desaturation while CO2 rises • Drug effect onset ≠ peak effect • Failure to check anesthesia/resuscitative equipment • Oxygen and nitrous oxide are oxidizers.

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