CONFESSIONS

1. CONFESSIONS Anesthesia Educators’ Team

2. Background • There was already an informal discussion forum called "Confessions” in our anesthesiology residency program • It used to discuss difficult anesthetic scenarios where no patient harm had occurred (defined here as near-hit-near-miss {NHNM} incidents) • Based on principle of sustaining practice of intellectual honesty without repercussions as similar to religious “confessions” in essence • No way related to our Anesthesia Quality and Assurance (Q&A) Committee forum include Mortality and Morbidity (M&M) forum • [confidential but not anonymous] • [used only partly for peer-educational activities] • However, there are numerous underreported near-hits-near-misses (NHNM) which can also provide valuable education regarding anesthetic practices

3. Background • The American Society of Anesthesiologists constituted the Anesthesia Quality Institute (AQI) and initiated National Anesthesia Incident Reporting System (AIRS) with the aim for dispersion of local Q&A sessions’ elicited observations for the educational benefits of nationwide readers. • AIRS system has novel Anonymous Electronic system for reported submissions. • This national concept further inspires local system to collect NHNMs anonymously. • This is the inspiration for the formalization of our Confessions Model.

4. Objectives • Similar to religious/spiritual confessions model, the objectives of this anonymous portal will be to: • Empower the confessors to acknowledge their mistakes or oversights • Facilitate the teaching/sharing of this knowledge with fellow colleagues • The aim of this study is to formulize our “Confessions” Model for • Voluntary and Anonymous reporting of NHNMs • Non-overlap with domains of Q&A committees and Risk Management committees. • The anonymous Confessions Model does not replace mandated Confidential Q&A forums • It ONLY relegate the legality/liability issues and accountability/answerability concerns to be managed by risk management agencies

5. Objectives • This model is an additional forum for intellectual stimulation in order for: • Anesthesia care providers to discuss NHNM incidents • Anesthesia care providers to analyze pathophysiology of observed NHNM incidents • Anesthesia care providers can learn from the new-found understanding • Anesthesia care providers can acknowledge their mistakes/oversights of diseases and clinical scenarios secondary to uniqueness of each individual patient, procedure and/or operator • Anesthesia care providers can educate the community through the anonymous confessions without any repercussions

6. Inclusion Criteria • All peri-anesthesia events are eligible for submission including and not limited to (as adapted from/similar to national AIRS model) • Out of ordinary reactions to drugs • Out of ordinary signs and symptoms of diseases • Out of ordinary procedural issues • Diagnostic dilemmas • Failure of systems • Who all can submit? • Anesthesiology Residents • Anesthesiology Sub-specialties' Fellows • Certified Registered Nurse Anesthetists (CRNAs) • Student Registered Nurse Anesthetists (SRNAs) • Anesthesiologists (Board-Certified or Board-Eligible)

7. Risks • There is minimal risk involved related to the breach of the anonymity of the confessors. The educators resolve to maintain the anonymity of the confessors by (as explained in the Methods Section): • Shredding of the original forms • Correction fluid use by the auxiliary educational staff for removing the identifying information if left mistakenly by the confessor on the forms • Sharing of the confessions not before one month after the submission to overcome any other care provider remembering the events when they were sharing the anesthesia care of the confessed near-miss event • Advocacy to the confessors to share only those observations that have not been locally discussed to maintain their anonymity when they actually share through this forum • Advocacy to the confessors that follow up to the confessions eliciting any questions/clarifications/comments will be re-submitted as anonymously (similar to the initial submission)

8. Methods • These NHNM events are collected in sequential order on 4 different forms as • FORM A Confession Submission (CS): written anonymously by the confessor • FORM B Confession Discussion (CD): anonymous comments of the peers in regards to CSs • FORM C Confession Follow Up (CFU): confessor's anonymous reply to CDs • FORM D Averted Confession (AC): written anonymously by peers as an event that was averted due to information learnt from previous confessions

9. Methods • Confession Forms (A, B, C or D) are submitted as printed typed documents to be placed in locked “Confessions” Boxes in Site-Chief’s Office in all other worksites except that Dr X’s office itself act as Confessional Box at X-Hospital (slide forms under office door). • Completed confession forms are collected at the end of each month • Confessions will be reviewed by the educators as follows: • Step 1. Removal of any identifying marks with correction white colored fluid • Step 2. Sorting of de-identified forms by the Q&A liaison officer to remove any confessions that were not NHNMs. These removed confessions can be anonymously discussed in Q&A forum. N.B. These confessions can be used in classroom teaching and discussions but these removed confessions (that are not NHNMs) can NOT be electronically shared

10. Methods • Step 3. The remaining confessions (NHNMs) are reviewed with the aims of • Better understanding of pathophysiology of confessions • Addressing the event management issues (if any) • Advocating plan for prevention of recurring confessions • Step 4. Reviewed confessions are shared via monthly email to anesthesia providers • For continuing medical education (CME) • For eliciting comments (CDs) as printed/typed forms • For continuing anonymous dialogue with confessors through his/her CFU forms • For encouraging more submissions (AC) if any NHNM is averted by electronically shared confessions • Step 5. Selected confessions ANONYMOUSLY shared by local educators with National Anesthesia Incident Reporting System

11. Methods • Educators’ Team should at least include • One Junior Anesthesiology Faculty • (the initial reviewer of the confessions) • First Senior Anesthesiology Faculty • (the educational supervisor for the reviewed and shared confessions) • Second Senior Anesthesiology Faculty as Q&A Liaison Officer • (the final sorter for removing Q&A eligible non-NHNM confessions) • One Paramedical/Secretarial Staff Member • (the collector, initial sorter and de-identifier for the submitted confessions)

12. Statistical Methods • Primary Outcome • Number of Averted Confessions per month as an objective indicator of Confessions Model’s success • Secondary Outcome • Number of Confession Submissions (CSs) per month over time (an indication of acceptance for model) • Number of Confession Discussions (CDs) and Confession Follow Ups (CFUs) per month as a learning interests indicator of anesthesia care providers’ group • Frequency of various characteristics (patients' and personnel's) among the submitted confessions

13. Our Experiences • "Confessions are NOT rare but Confessing itself is rarity“ • It has out-rightly failed to prompt any of the "confessors" to "confess" their "confessions" • Hence there are no formal outcomes to report (YET) • However, Vision for Future: Expanding Existing Informal Confessions Beyond Confined Boundaries of Closed Door Resident Didactics • “We Knew It May NOT Fly, Still Has Been Worth THE Try”

14. Our Experiences • Few of historical examples that have strengthened developers' resolve to promote/propagate Confessions Model • Management of esophageal injury in a post-cardiac surgery patient in ICU as an intern ensured extra-vigilant TEE operator. • Difficult endotracheal intubation in supine position (s/p gastric pull-through procedure) popularized intubation in sitting position. • An observant educational meeting attendee/listener to highlighted asymptomatic hypoxemia due to PFO diagnosed immediately afterwards two PFO/shunt patients avoiding unwarranted mechanical ventilation in them. • An observant educational meeting attendee/listener to story of mother keeping child’s airway intact in prone position against detached tonsils applied the same information for intraoperative diagnosis of detached tonsils during endotracheal intubation. • Cardiothoracic surgeon’s teaching rounds regarding fentanyl-induced pancreatitis in post-cardiac surgery patients prompted ICU rotator to consider pain management itself causing physical pains such as fentanyl induced vesico-ureteric spasms complicating pain management.

15. Our Recommendations • Place Locked “Confessional Boxes” in Anesthesia Care Providers’ LOUNGES rather than Worksite Chief’s Offices • Mandate Anesthesiologists (Board-Certified or Board-Eligible) to “Confess” as Surrogate for the Supervised Residents/Fellows/CRNAs/SRNAs during the submitted NHNMs • Inspire Residents/Fellows/CRNAs/SRNAs to “Confess” even if they were NOT directly involved in submitted NHNMs but had enough first-hand/direct knowledge of submitted NHNMs • Averted Confessions can actually be used as Sign of Improved Patient Outcomes directly related to the “Confessions” Model that can be turned into Money-Saved-Money-Made-Model in current paradigm of Outcome-Based-Reimbursements