October 3, 2010
Prevent Wrong Site Surgery – a quarterly update
Of particular interest is that the number of reports for wrong site surgery in Pennsylvania appears to be declining. However, wrong site placement of local anesthetic blocks is becoming an increasing percentage of the reports.
For example wrong site blocks constituted 20 percent of the wrong site events in the first six months of data reporting to the Pennsylvania Patient Safety Authority, but they accounted for 44 percent of wrong site events in the most recent six months of reporting. These are two of the four examples provided by the Pennsylvania Patient Safety Authority:
- A patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block.
- A patient was admitted for surgery [on the right knee]. The patient was seen by the anesthesiologist, who asked the patient which knee was to be operated on. The patient stated “left.” The anesthesiologist performed the nerve block on the left side. The patient was taken to the OR for the right-knee surgery, where it was determined the nerve block was done on the wrong side.
Doing a formal time-out before an anesthetic block could potentially eliminate about 27 percent (92 of 337) of the wrong site errors reported in the surgical suite. However, based on the data from the Preventing Wrong-Site Surgery Project, a time-out before an anesthetic block does not eliminate the need to do a time-out just before the start of the surgical procedure, with the site marking visible in the prepped and draped surgical field.
In the opinion of the Pennsylvania Patient Safety Authority, the 2010 revision of the Joint Commission’s Universal Protocol does not help the confusion about when to do the time-out. The 2009 version states that the time-out should be done before the start of anesthesia; the 2010 version reverts to stating that the time-out should be done before the incision.
Based on multiple studies from the Preventing Wrong-Site Surgery Project, the Authority strongly advises that a formal time-out be done with the anesthesia provider just before any anesthetic block is placed and that another time-out be done with the surgeon just before the incision, unless the surgeon performs the anesthetic block and incision in continuity after the surgical field has been prepped and draped.
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September 3, 2010
Retained objects – anesthesia related anesthesia related
The Agency for Healthcare Research and Quality has a section called case and commentary, some of which are of interest to anesthesiologists. In October 2009, it presented a case that I briefly summarize as follows:
One day after a vascular bypass procedure on the right-upper extremity that started under MAC but was converted to general endotracheal anesthesia, this 70-year-old man complained that whenever “he tried to drink any liquid it would come right out his nose.” He promptly demonstrated this phenomenon when members of the surgical team expressed their skepticism. The patient took a gulp of orange juice with the physicians present and they witnessed that most of the juice came out of his nose and spilled onto his hospital gown.
Concerned about a pharyngeal fistula or some other anatomic abnormality, the surgical team consulted an otorhinolaryngologist who discovered a nasopharyngeal airway lodged within the nasal cavity (not visible externally), which apparently acted as a retrograde conduit of fluid. Chart review revealed that a nasopharyngeal airway had been used during the MAC portion of the patient’s surgery the previous day.
The article notes that aspirated nasal airways have been associated with a number of complications, including airway obstruction and that symptom may not present immediately. They noted one case in which an aspirated nasal airway was not discovered for weeks and was only discovered after investigation for persistent cough and recurrent chest infections (the device was lodged within the trachea near the right mainstem bronchus).
The typical nasopharyngeal airway has no radio-opaque strip, RFID tag, or suture tail. Anesthesia devices are not typically “counted,” so the only person who may know that a nasopharyngeal airway was used is the person who placed it. It would seem prudent to make sure that insertion and removal of nasopharyngeal airways are clearly noted on the anesthesia record, that the presence of nasopharyngeal airways are part of any “handoffs," and that changes in anesthetic plan are accompanied by a reevaluation of the need for any nasopharyngeal airways or other support devices that may have been placed.
Read the entire presentation along with a nice discussion by Christopher R. Lee, M.D., from the Department of Anesthesiology and Pain Medicine, University of Washington Medical Center.
The most recent case
Case archive
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June 4, 2010
Wrong site surgery – the five year national experience
From the August 2009 Newsletter of the Premier Safety Institute:
With 2,700 cases of wrong-site surgery continuing to occur annually, experts recommend more consistent adoption of the Universal Protocol (UP), or in this case a defined alternative process when site-marking is impractical.
A recent review of the National Practitioner Data Bank and additional closed claims databases for wrong-site procedures estimated that wrong-site surgery continues to occur approximately 1,300 to 2,700 times annually in the United States, despite the Joint Commission (TJC) requirement for a UP five years ago. Read More.
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May 28, 2010
A patient unexpectedly does not “wake up” at the end of an anesthetic
and is taken to the PACU
Dr. Falk discusses what needs to be done when a patient unexpectedly does not “wake up” at the end of a general anesthetic: An unresponsive patient in the recovery suite should be approached as if they have a life threatening condition.
Immediate evaluation and survey should include the basics of resuscitation. Can the patient maintain an airway? Are they respiring effectively? Are hemodynamic parameters adequate? If this initial survey is satisfactory, further investigation to determine the cause of unconsciousness should be performed. Read More.
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