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Preventing Operating Room Disasters Before They Happen

2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future. Preventing Operating Room Disasters Before They Happen. Rafael Ortega, MD Associate Professor of Anesthesiology. Boston University School of Medicine May 18, 2006. 9:30-10:00am. QUESTION:.

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Preventing Operating Room Disasters Before They Happen

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  1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Preventing Operating Room Disasters Before They Happen Rafael Ortega, MD Associate Professor of Anesthesiology Boston University School of Medicine May 18, 2006 9:30-10:00am

  2. QUESTION: Have you ever been in an operating room fire? • Yes • No 0/0

  3. QUESTION: How important are simulation and drills in the management of operating room disasters? • Very important • Somewhat important • Minimally important • Not important 0/0

  4. 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)

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

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

  7. 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

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

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

  10. history / physical exam / medical record / anesthesia record / lab work / consults / etc. …more preparation needed… Normal MP l Small jaw MP ll Small jaw Short neck MP lll Small jaw Short neck Obese Goiter MP lV

  11. match risk waste match Preparedness Complexity

  12. Preparedness Complexity

  13. Preparedness Complexity

  14. 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

  15. Aligned Holes Example: wrong site / wrong patient Failed or Absent Defenses Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

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

  17. 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.

  18. 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: an opportunity to learn from errors. Medical Teacher. 27(3):193-9, 2005 May. • Berkenstadt H et al: The feasibility of sharing simulation-based evaluation scenarios 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.

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

  20. Illustrative Examples • Wrong Dose: Communication Error • Airway Management – Fixation Error • Wrong Gas Administration • Anaphylaxis • Malignant Hyperthermia • Fires

  21. Communication Error “eight thousand of heparin” vs. “a thousand of heparin”

  22. Communication Error Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding. Control Room aboard USS Seawolf submarine. (courtesy of www.navy.mil)

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

  24. 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.

  25. "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 Fixation Errors Types and Countermeasures Error Type Description Countermeasure (Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2005)

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

  27. 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." Hazardous Attitudes and their Antidotes Attitude Example Antidote

  28. Wrong Gas: a rare event

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

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

  31. 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.

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

  33. 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)

  34. 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

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

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

  37. Malignant Hyperthermia

  38. Malignant Hyperthermia

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

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

  41. Amyloidosis

  42. Compartment Syndrome

  43. Impalement of the Brain

  44. Broken Needle in Aorta

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

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

  47. Oxidizer Fire Triad Fuel Ignition Source The Fire Triad

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