preventing or disasters before they happen preventing or disasters before they happen rafael ortega,...

Preventing OR DisastersBefore They Happen

Preventing OR DisastersBefore They Happen

Rafael Ortega, MDProfessor of Anesthesiology

Rafael Ortega, MDProfessor of Anesthesiology

Boston University School of Medicine

September 11, 2010

Boston University School of Medicine

September 11, 20109:30 AM -10:30 AM9:30 AM -10:30 AM

Connecticut State Society of Anesthesiologists

Connecticut State Society of Anesthesiologists

Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask:safety revisited. Anesthesiology 1996;84(4):965- 75.

Ortega RA: Leroy Vandam: An anesthesia journey. Journal of Clinical Anesthesia (2005) 17, 399–402

“One day, in his inimitable way, Vandam assigned Pierce the subject of “anesthesia accidents” to be given as a resident’s lecture. Years later, Dr Pierce, with others, founded one of the most influential organizations in anesthesiology, The Anesthesia Patient Safety Foundation.”

Accident?Accident?

Why do accidents happen?Why do accidents happen?

• Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.

Wagenaar and Groeneweg

• Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.

Wagenaar and Groeneweg

Family Sues in Operating Room Fall

“Matriarch suffered a fatal head injury Catherine O'Donnell, was a lifelong Dorchester

resident… “

By Jonathan Saltzman Globe Staff

January 29, 2008

ObjectivesObjectives

• To review conditions O.R. disasters have in common

• To present examples of O.R. disasters (or near disasters)

• To recommend strategies to minimize O.R. mishaps

• To review conditions O.R. disasters have in common

• To present examples of O.R. disasters (or near disasters)

• To recommend strategies to minimize O.R. mishaps

Anesthesia RiskAnesthesia Risk

• The rates of morbidity and mortality depend on the definitions.

• Data demonstrates that risk directly attributable to anesthesia has declined over time.

• The rates of morbidity and mortality depend on the definitions.

• Data demonstrates that risk directly attributable to anesthesia has declined over time.

Liquid Oxygen LeakLiquid Oxygen Leak

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

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

It can happen to you too…It can happen to you too…

Boston Medical CenterJune 15, 2006

Boston Medical CenterJune 15, 2006

It’s Everyone’s Business!It’s Everyone’s Business!

Chest. 2010 Feb;137(2):443-9.Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety

 Am J Surg. 2010 Jan;199(1):60-5.

Factors compromising safety in surgery: stressful events in the operating room. 

J Health Serv Res Policy. 2010 Jan;15 Suppl 1:48-51.Errors in the operating theatre--how to spot and stop them.

 Surgeon. 2010 Apr;8(2):87-92. Epub 2010 Feb 18.

Surgical fires, a clear and present danger. 

Jt Comm J Qual Patient Saf. 2010 Mar;36(3):133-42.Does teamwork improve performance in the operating room? A multilevel evaluation.

 Surgeon. 2010 Apr;8(2):93-95.

Safe surgery, the human factors approach. 

Qual Saf Health Care. 2010 Feb;19(1):69-73.Promoting patient safety through prospective risk identification: examples from peri-operative care

Potential CrisesPotential Crises

• Anaphylaxis• Transfusion Reactions• Malignant Hyperthermia• Difficult Airway• Fires• Electrical Safety• Cardiac Arrest• Etc.

• Anaphylaxis• Transfusion Reactions• Malignant Hyperthermia• Difficult Airway• Fires• Electrical Safety• Cardiac Arrest• Etc.

But what do they have

in common?

Features in CommonFeatures in Common

• Critical incidents• Reason’s Swiss Cheese• Relatively Rare• Training (and re-training) Required• Communication• Fixation Errors• Reportable• Litigation Prone

• Critical incidents• Reason’s Swiss Cheese• Relatively Rare• Training (and re-training) Required• Communication• Fixation Errors• Reportable• Litigation Prone

What is a “Critical Incident”?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.

• 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.

BMC and Critical IncidentsBMC and Critical Incidents

• Root-Cause Analysis (Risk Management)

• On-line reporting

• 31-RISK Beeper (24 / 7 / 365)

• Physician Vice-President for Quality and Patient Safety

• Root-Cause Analysis (Risk Management)

• On-line reporting

• 31-RISK Beeper (24 / 7 / 365)

• Physician Vice-President for Quality and Patient Safety

• Analyze all critical incidents (including the ones that could have led to a problem)

• Use a standardized approach to identify causes, system failures, and opportunities for improvement.

• Where was the hole in the Swiss cheese?

• Analyze all critical incidents (including the ones that could have led to a problem)

• Use a standardized approach to identify causes, system failures, and opportunities for improvement.

• Where was the hole in the Swiss cheese?

RecommendationRecommendation

What is the Role of Simulation?What is the Role of Simulation?

What is the Role of Simulation?What is the Role of Simulation?

• Improving on Reality: Can Simulation Facilitate Practice Change? Anesthesiology. 112(4):775-776, April 2010.

• Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation Anesthesiology . 112(4):1041-1052, April 2010.

• Anesthesiology Residents' Performance of Pediatric Resuscitation during a Simulated Hyperkalemic Cardiac Arrest. Anesthesiology. 112(4):993-997, April 2010.

• Acquisition of Critical Intraoperative Event Management Skills in Novice Anesthesiology Residents by Using High-fidelity Simulation-based Training. Anesthesiology 112(1):202-211, January 2010.

• Simulation Training and Assessment: A More Efficient Method to Develop Expertise than Apprenticeship Anesthesiology. Anesthesiology.112(1):8-9, January 2010.

• Improving on Reality: Can Simulation Facilitate Practice Change? Anesthesiology. 112(4):775-776, April 2010.

• Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation Anesthesiology . 112(4):1041-1052, April 2010.

• Anesthesiology Residents' Performance of Pediatric Resuscitation during a Simulated Hyperkalemic Cardiac Arrest. Anesthesiology. 112(4):993-997, April 2010.

• Acquisition of Critical Intraoperative Event Management Skills in Novice Anesthesiology Residents by Using High-fidelity Simulation-based Training. Anesthesiology 112(1):202-211, January 2010.

• Simulation Training and Assessment: A More Efficient Method to Develop Expertise than Apprenticeship Anesthesiology. Anesthesiology.112(1):8-9, January 2010.

Expertise vs. Experience

• Self-confidence• Excellent communication skills• Adaptability• Risk tolerance • Attention to what is relevant• Ability to identify exceptions to the rules• Effective performance under stress• Ability to make decisions• Quick reactions based on incomplete data

Anesthesiology:Volume 107(5)November 2007pp 691-694 Experience ≠ Expertise: Can Simulation Be Used to Tell the Difference?

Editorial - Weinger, Matthew B. M.D.

Expertise vs. Experience

Simulation at BMC - AnesthesiaSimulation at BMC - Anesthesia

Simulation in HealthcareSimulation in Healthcare

RecommendationRecommendation

• Simulate, conduct drills, review strategies. Although ideal, a simulation laboratory is not strictly necessary to engage in simulation.

Illustrative ExamplesIllustrative Examples

• Wrong Dose: Communication Error

• Missing Kidney: Communication Error

• Airway Management: Fixation Error

• Wrong Gas Administration

• Malignant Hyperthermia

• Wrong Dose: Communication Error

• Missing Kidney: Communication Error

• Airway Management: Fixation Error

• Wrong Gas Administration

• Malignant Hyperthermia

“eight thousand of heparin”

vs.

“a thousand of heparin”

“eight thousand of heparin”

vs.

“a thousand of heparin”

Communication ErrorCommunication Error

Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding. 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)

Communication ErrorCommunication Error

Meant

Said

Heard

Understood

Done action

Closing the loop

X Not said

X Not understood

X Not done

Modified from Miller’s Anesthesia. Elsevier 2009

Not heardX

Stairway of CommunicationStairway of Communication

RecommendationRecommendation

• Use Closed-Loop Communication whenever possible.

The Missing KidneyThe Missing Kidney

In December 1954, Dr. Murray performed the world's first successful kidney transplant between the identical Herrick twins at the Peter Bent Brigham Hospital.

“The Ether Screen”“The Ether Screen”

Transparent DrapesTransparent Drapes

Transparent DrapesTransparent Drapes

Transparent Ether Screens: The Road to New TransparencyOrtega R, Gonzalez M, Lewis K

ASA Newsletter , February, 2010

Transparent DrapesTransparent Drapes

Transparent Ether Screens: The Road to New TransparencyOrtega R, Gonzalez M, Lewis K

ASA Newsletter , February, 2010

Why Communication Fails in the Operating Room J Firth-Cozens

Qual Saf Health Care 2004;13:327

Why Communication Fails in the Operating Room J Firth-Cozens

Qual Saf Health Care 2004;13:327

• Team instability - different scrub nurses• Team policies about communication - proper introductions• Disallowing distractions - noise • Redundancy - allows people time to communicate• Sufficient resources - equipment • Stress – what stress?• Introverts Vs. Extroverts – many examples• Professional language - way of maintaining power?• Team meetings outside immediate task - enhancing rapport

• Team instability - different scrub nurses• Team policies about communication - proper introductions• Disallowing distractions - noise • Redundancy - allows people time to communicate• Sufficient resources - equipment • Stress – what stress?• Introverts Vs. Extroverts – many examples• Professional language - way of maintaining power?• Team meetings outside immediate task - enhancing rapport

BUMC BandBUMC Band

Losing the AirwayLosing the Airway

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

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

The Tube is in the Trachea!The Tube is in the Trachea!

Leissner KB, Ortega RA, et. al. Kinking of an endotracheal tube within the trachea: a rare cause of endotracheal tube obstruction. Journal of Clinical Anesthesia (2007) 19, 75–81

ETTForeign Body Anesthesia

Machine

Ascaris

ETTKinking

ETTDefective

TurbinateAvulsion

Chest RigiditySevere

Bronchospasm

Fixation ErrorsFixation Errors

Human errors (1/3 of error: FIXATION)Human errors

(1/3 of error: FIXATION)

DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation.

Anesth Analg. 1990 Jul;71(1):77-82.

Equipment failures >

Fixation Errors Types and Recommended Countermeasures

Fixation Errors Types and Recommended Countermeasures

"This and only this!" Persistent failure to revise a diagnosis

Accept possibility that first assumptions may be wrong

"Everything but this!" failure to commit to definitive treatment of major problem

Rule out worst case scenario

"Everything is OK!" Persistent belief that no problem is occurring

Artifacts are the last explanation for changes in critical values

CountermeasureError Type Description

(Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2007)

A 66-year-old woman admitted to SICU after CABG.History of severe hypertension on a nitroprusside drip.

The surgeon had warned about a friable aorta.

75

100

125

5 Minutes

She has severe hypertension…..75

100

125

150

10 Minutes

She is pain…..75

100

125

150

175

15 Minutes

She is anxious…..

100

125

150

175

200

75

75

100

125

150

175

200

225

20 Minutes

Nitroprusside dose is insufficient…..

75

100

125

150

175

200

225

>30 Minutes

Oh no!

Initial State

A

B

C

D

Adapted from: E. Fioratou et al. No simple fix for fixation errors Anaesthesia, 2010, 65, pages 61–69

It costs 2 cents to open a link and 3 cents to close it again

Goal State

15 Cents

2 cents to open a link x 3 = 6 3 cents to close a link x 3 = 9

Total = 15

“Lateral Thinking”

97%1 2

3

if X (local signs) then do Y (a particular intervention).

A rule of thumb, simplification, or educated guess that reduces or limits the search for solutions in domains that are difficult and poorly understood.

Pattern Matching Machine

if X (local signs of a problem exist)

then it is probably Y (a particular condition to be managed)

or

Heuristics

RecommendationRecommendation

• Be aware of fixation errors and strategies to prevent them.

• Be aware of fixation errors and strategies to prevent them.

Wrong Gas: a rare eventWrong Gas: a rare event

Incidents with GasesIncidents 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.

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.

Fixation: Everything is OKFixation: Everything is OK

• Patient complaining of pain

• Free air the abdomen

• Cost center discrepancies

• Patient complaining of pain

• Free air the abdomen

• Cost center discrepancies

A Close CallA Close Call

Good IdeaGood Idea

FDA MAUDE DATABASEFDA MAUDE DATABASE

PROBLEMS WITH:Teamwork and Communication

Design, Construction and MaintenanceEquipment Standardization

Drug Labeling, Purchasing, Stock Control, and Delivery

Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia

Providers

PROBLEMS WITH:Distraction

Momentary InattentionForgetting

Losing the PicturePreoccupation

Fixation(Psychological Antecedents of Unsafe Acts)

The Organization The IndividualAdapted from: Reason: Qual Saf Health Care 2005;14:56–61

PROBLEMS WITH:Teamwork and Communication

Design, Construction and MaintenanceEquipment Standardization

Drug Labeling, Purchasing, Stock Control, and Delivery

Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia

Providers

PROBLEMS WITH:Distraction

Momentary InattentionForgetting

Losing the PicturePreoccupation

Fixation(Psychological Antecedents of Unsafe Acts)

what goes on in the head of the practitionerbeyond a certain point—extremely difficult to

control

The Organization The Individual

Hard to Control

Controllable

“Unsafe acts are like mosquitoes. They can be swatted or sprayed, but they still keep coming. The only effective remedy is to drain the swamps in which they breed.”

Adapted from: Reason: Qual Saf Health Care 2005;14:56–61

The SwampThe Swamp

The GardenThe Garden

Defenses

IncidentAccident

Management Decisions

Organizational Processes

Corporate Culture

OR Executive

Sequence begins with negative consequences of

processes :decisions regarding

planning, scheduling, forecasting, designing,

specifying, communicating,

regulating, maintaining, etc.

Error-ProducingConditions

Violation-ProducingConditions

Operating Room

Latent failures transmitted along organizational

pathways to workplace creating local conditions

that promote the commission

of errors and violations: understaffing, fatigue, technical problems, high work load, poor

communication, conflicting goals, inexperience, low

morale, teamwork deficiencies, etc.

Errors

Violations

OR Worker

Unsafe acts are likely to be committed, but

only few penetrate the defenses to produce

incidents.

Inheritors (Mosquitoes)Instigators (Swamp)

Adapted from: Reason: Qual Saf Health Care 2005;14:56–61

Stages in the Development of an Organizational Accident

Malignant HyperthermiaMalignant Hyperthermia

Malignant HyperthermiaMalignant Hyperthermia

DantroleneDantrolene

Rosenberg H: Anesthesiology News March 2010

Malignant HyperthermiaMalignant Hyperthermia

Rosenberg H: Anesthesiology News March 2010

A. Line InfectionA. Line Infection

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

AmyloidosisAmyloidosis

Compartment SyndromeCompartment Syndrome

Impalement of the Brain Impalement of the Brain

Broken Needle in Aorta Broken Needle in Aorta

Ventilator Failure 1Ventilator Failure 1

Ortega RA, Vrooman B, Hito r: Another Cause for Ventilator Failure. Anesthesiology. Anesthesiology. 104(6):1351, June 2006

Ventilator Failure 2Ventilator Failure 2

Ortega RA. Zambricki ER. Fresh gas decoupling valve failure precludes mechanical ventilation in a Draeger Fabius GS anesthesia machine. Anesthesia & Analgesia. 104(4):1000; 2007 Apr

Administrative Guidelines for Response to an Adverse Anesthesia Event

Journal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Febwww.APSF.org

Administrative Guidelines for Response to an Adverse Anesthesia Event

Journal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Febwww.APSF.org

• Primary anesthetist concentrates on continuing patient care.• Notify a physician responsible for supervision of anesthesia

activities• Sequester equipment• Contact the hospital Risk Manager immediately • Anesthesiologist and other individuals document relevant

information • After discussion with the incident supervisor, write on medical record

relevant information about what happened and actions taken• Complete and file incident report as soon as practical• State only facts. Do not use judgmental terms • Consult early and frequently with the surgeon.• Immediately call other consultants who may help improve long term

care

• Primary anesthetist concentrates on continuing patient care.• Notify a physician responsible for supervision of anesthesia

activities• Sequester equipment• Contact the hospital Risk Manager immediately • Anesthesiologist and other individuals document relevant

information • After discussion with the incident supervisor, write on medical record

relevant information about what happened and actions taken• Complete and file incident report as soon as practical• State only facts. Do not use judgmental terms • Consult early and frequently with the surgeon.• Immediately call other consultants who may help improve long term

care

SummarySummary

Simulate Avoid Fixation