Test 4: Risk Management Flashcards
What is safety monitoring?
Extending the human senses through electronic monitoring.
-Has dramatically improved anesthesia patient safety
-Ex: Capnography and pulse ox
What are the complications that contribute the highest percentages to anesthesia-related mortality?
-Adverse effects anesthesia in therapeutic use > 40%
-Opioids and analgesics ~ 20%
-Unspecified general anesthesia and unspecified anesthetic both > 10%
What are the malpractice claim areas with a reported mortality increase?
-Regional anesthesia (16%)
-Chronic pain management (18%)
-Acute Pain (9%)
Which area has had decreasing mortality malpractice claims?
-Surgical anesthesia has declined from 80% to 60%
Describe the relationship between physical status and mortality?
Comorbidities increase risk!!
-PS 1: 0.04 per 10,000 (0.0004%)
-PS 2: 0.5 per 10,000 (0.005%)
-PS 3: 2.7 per 10,000 (0.027%)
-PS 4: 5.5 per 10,000 (0.55%)
What is the leading outcome in the ASA Closed Claims Project?
Death, 26% of the complications
What is PS Class 1?
normal healthy patient, no functional limitations
What is PS Class 2?
patients with mild systemic disease, no functional limitations (Controlled HTN/Asthma/DM type 2, Tobacco, Pregnancy)
What is PS Class 3?
Patients with moderate-severe disease with some functional limitation (Poor control HTN/COPD/CHF/CAD with old MI, Morbid obesity)
What is PS Class 4?
Patients with severe systemic disease that is a constant threat to life, possible risk of death (Unstable angina/ Symptomatic COPD with supplemental O2/Hepatorenal failure)
What is PS Class 5?
Patients who are moribund, not expected to survive > 24 hrs without surgery. Imminent risk of death
-Multiorgan failure
-Sepsis with hemodynamic instability
-Hypothermia
-Poorly controlled coagulopathy
What is PS Class 6?
Patients declared brain dead, organ donors
What is PS Class E?
Emergency
What is morbidity?
Indicative of disease, incorporating any complication, excluding death occurring during the perioperative period
What are the most common events leading to injury in anesthesia claims?
-Regional blocks (20%)
-Respiratory events (17%)
-CV events (13%)
-Equipment problems (10%)
What is Minor Morbidity?
Moderate distress without prolonging hospital stay. No permanent complications (e.g., postoperative nausea and vomiting).
What is Intermediate Morbidity?
Serious distress prolonging hospital stay. No permanent complications (e.g., dental injury).
What is Major Morbidity?
Permanent disability or complication (e.g., spinal cord injury; anoxic brain injury).
Which areas in anesthesia have increasing morbidity claims?
Acute pain (8%)
Chronic pain (18%)
MAC (10%)
Which areas in anesthesia have decreasing morbidity claims?
Obstetrics
Which areas in anesthesia have unchanging morbidity claims?
Regional Anesthesia (20-25%)
What are examples of adverse outcomes associated with minor morbidity? (Overall minor morbidity incidence is 20%)
Hoarseness 14-50%
PONV 10-79%
Accidental dural puncture 0.5%
Equipment malfunction 0.25%
Medication error 0.1%
How is human error a significant concern to Periop M&M?
Identified in >50% of anesthesia-related deaths.
-Teamwork and communication contributing to 43% to 65% of sentinel events occurring in the operating room (e.g., wrong side/site, transfusion error).
-Communication breakdown (both oral 36% and written 20%)
-absence of help (44% of failures) when needed
Anesthetic complications are the ___th leading cause of pregnancy-related mortality.
7th leading cause (1.6% of pregnancy related deaths).
-Airway obstruction/hypoventilation (emergence and recovery)
-System errors: monitoring, missed diagnoses
-Obesity and African American race are risk factors
How does Advanced Age contribute to periop M&M?
-Inc # of older patients
-Greatest challenge is preventing, detecting, and managing M&M
-POD and POCD
-Frailty
What is Postoperative Delirium (POD)?
Characterized by disruption of perception, thinking, memory, psychomotor behavior, sleep-wake cycle, consciousness, and attention.
-Relationship between pre-existing cognitive impairment and POD
-Inc risk of perioperative mortality, institutionalization, and dementia
What are risk factors for postoperative delirium?
-Age > 65 years old
-Renal insufficiency and metabolic derangements
-Poorly controlled pain: multimodal management
-Polypharmacy (pyschoactive drugs)
-Functional impairment
-Urinary retention and presence of a urinary catheter
T/F: You should always use Benzos, antihistamines, and anticholinergic in geriatric patients.
False; The use of benzodiazepines, antihistamines, and anticholinergics are associated with the development of delirium and should be avoided during the perioperative period.
What is Postoperative Cognitive Dysfunction (POCD)?
An array of cognitive impairments such as memory deficits, difficulty with concentration, impaired comprehension, and delayed psychomotor speed.
-Onset weeks to months postop
-Inability to work, decline in ADLs, and possible need for assistive care
-Establish baseline cognitive function
-Risk: age > 65 years old
-Prevent with maintaining O2 and cerebral perfusion and short/minimally invasive surgeries
What is Frailty?
Biologic state associated with multisystem physiologic deterioration
-increased vulnerability to adverse outcomes (inc risk of complications, inc LOS, more likely to be discharged to skilled or assisted living)
-decreased resistance to stressors
-Primary vs Secondary
What is primary frailty?
Occurs as part of the intrinsic process of aging.
What is secondary frailty?
Related to the end-stage of chronic illnesses and is caused by inflammation and wasting, for example heart failure, COPD, inflammation, and wasting associated with cancer.
What are the physiologic parameters of frailty?
-Grip weakness
-weight loss
-walking speed
-energy level
-decrease in physical activity
Does anesthesia cause MI?
Not rly; Cardiac arrest during anesthesia is usually a concomitant and not a causative factor.
-Less frequent during NA compared to GA
What are causative factors of MI?
-Preoperative complications (65%): Patient comorbidities, inadequate risk estimation, and misjudgment/human error
-Surgical procedures (24%): excessive surgical bleeding
-Intraoperative pathologic events (9%): MI, PE, dysrhythmias
-Anesthetic management (2%): airway, medication error, infusion/transfusion mishaps
What is the most common underlying substrate of Sudden Cardiac Arrest (SCA)?
Ischemia and/or LV dysfunction
-95% victims die before emergency assistance ~ 325k/yr
What is Hypertrophic Cardiomyopathy?
-The most common underlying cause of sudden cardiac death in young athletes.
-Long QT Syndrome
-60% asymptomatic at diagnosis
-Can be provoked by sudden SNS stimulation (Induction/Intubation), QT prolongation (meds), and drugs with adrenergic stimulation (ketamine, pancuronium)
-Tx: BBs preop, HR < 130 BPM, avoid meds that prolong QT
-Mg, temp pacing for Torsades
What drugs are associated with QT Prolongation?
-Amiodarone
-Procainamide
- -floxacin, -mycin, and -azole antimicrobials
-Antidepressants
-Haldol, droperidol
-Methadone
What is the most common cardiovascular complication after noncardiac surgery?
Periop MI
-Patients who suffer a perioperative MI have a 30-day mortality of between 11.6% and 21.6%.
-Most MIs occur within 48 hours of surgery (74.1%) and 65.5% are asymptomatic.
What are independent predictors of periop MI? (KNOW THIS!!)
-Increase in baseline heart rate for Every 10-beats/min
-History of stroke
-Major vascular surgery
-Preoperative serum creatinine level greater than 2.0 mg/dL (chronic kidney disease)
-Advanced age
-Emergency or urgent surgery
-Serious bleeding and transfusion > 2 units
Why does airway mortality occur?
As a result of failure to VENTILATE
What is a difficult airway?
The clinical situation in which anticipated or unanticipated difficulty or failure is experienced by a physician trained in anesthesia care, including but not limited to one or more of the following: facemask ventilation, laryngoscopy, ventilation using a supraglottic airway, tracheal intubation, extubation, or invasive airway.
How can you manage periop complications related to Airway?
-Airway plan A,B,C
-Early recognition that current plan isn’t working and good communication
What complications are associated with the Laryngeal Mask Airway (LMA)?
-Failed LMA placement 1-5% (this decreases with operator experience)
-Inadequate seal, laryngospasm, and aspiration gastric contents
What is the gold standard for intubation in the Anticipated difficult airway?
Fiberoptic Bronchoscope with spontaneous ventilation (awake)
Video Laryngoscopy also emerging
What are complications associated with Endotracheal Intubation?
Hemodynamic and Anatomic
-50% of Dental trauma occurs during laryngoscopy
-Sore throat/hoarseness (40%)
-Injury to lips, tongue, oropharynx, VC, and trachea
What are some tips from the ASA Difficult airway algorithm?
-Strategy/techniques should be based on provider’s experience, available resources, and competency of help
-Keep NC on and head elevated throughout
-Awake technique
-possibly postpone case
What cases and when is awareness under anesthesia most likely to occur?
-Explicit recall incidence is 0.023% (consciousness and memory)
-Trauma, OB, and CT surgery most at risk
-Most often occurs during maintenance of anesthesia (less during induction, and least during emergence)
-Associated with patient mvmt, tachycardia, and HTN
-Can develop PTSD, sleep disturbances, nightmares, fear of future anesthesia/surgery, and daytime anxiety
What are risk factors for awareness under anesthesia?
-Female sex
-Younger adults
-Obesity
-Clinician experience
-Hx previous awareness
-After duty hours or emergency procedures
-Type of surgery: Trauma, OB, CT
-Use of NDMRs
Most anesthetics cause ______ amnesia (loss of memory after medications), but not reliable ______ amnesia (loss of memory before medications).
Most anesthetics cause anterograde amnesia (loss of memory after medications), but not reliable retrograde amnesia (loss of memory before medications)
What is Bispectral Index (BIS) Monitoring?
-The analysis and processing of EEG signals that are displayed as a value between 0-100, representing level of consciousness.
-100 = awake
-0 = absence of brain activity
-Values between 40-60 suggest adequate GA.
-Below 40 is deep hypnotic state and associated with increased M&M.
-Can be used to reduce incidence of recall under anesthesia (Controversial, can be used in high-risk patients).
What is organizational learning in regards to management of complications?
-important for improving patient safety
-Framework for handling critical events
-Effective communication between all parties
-Support for the patient, family, and healthcare provider
What is important regarding incident reporting?
-Critical incidents must be reporting and investigated systematically
-Reported even if positive or negative outcome
-Any death within 48hrs of anesthesia is evaluated
-Effective risk management depends on a reporting culture
What is your first obligation when a critical incident occurs?
Protect the patient from further harm, provide care required, and mitigate further injury.
What is a Root Cause Analysis?
Based on the premise that adverse events are caused, not by individual human errors, but by combinations of factors linked to organizational processes and structures, by which errors are missed and adverse events are not prevented.
-The objective of an RCA is to systematically uncover multiple factors or causal chains that contribute to a critical incident, developing systems changes to make it less likely that the incident will recur. During this process, the importance of unbiased investigation and blame avoidance is important.
-Organized in sequential steps
What are the steps of a Root Cause Analysis?
1) Identifying the incidents/problem statement
2) Organizing a multidisciplinary team to conduct the RCA
3) Exploring processes involved
4) Collecting facts and written statements from all involved
5) Performing an evidence-based literature review
6) Identifying possible causes
7) Analyzing the data
8) Proposing possible actions
9) Writing a report
10) Reevaluating actions taken
How should you notify patients/families of incidents?
Open Disclosure
-Accurate information
-Immediate consequences and remedial action
-Expression of regret
-Efforts to prevent incident from reoccurring
-Not disclosing information is associated with lower patient satisfaction, less trust, and stronger negative emotional responses.
-Patients/Families want to prevent incident from happening again.
-Providers must comply with state law and/or institutional policies regarding disclosure and not view disclosure as an individual endeavor
What is the process for effective disclosure?
-Continuation of care
-Acknowledgement of incident and patient consequences
-Information on what happened and what to expect
-Apology (when appropriate)/expression of regret
-Advice about necessary treatment
-Information about preventing recurrence
-Tangible support regarding physical, psychological, social, and financial consequences
Who is the Second Victim?
A health care provider involved in an unanticipated adverse patient event who becomes victimized. The second victim is often traumatized by the critical/adverse event.
-Feeling personally responsible
-Creates serious health problems
-PTSD, sleep disturbances, and irritability
-Clinical performance deficits: second guess skills and knowledge
-Difficult to work clinically, burnout, and decreased job satisfaction
What does “Human Factors” describe?
Human performance and behavior related to interaction with the environment.
-Identified in 51-77% of anesthesia-related deaths
-Lack of experience or competence in 89% of human failure related deaths
-Errors of judgement/analysis 11% of these deaths
-Systematic approach to safety is needed at organizational level (manuals, checklists, simulation)
-Resilience needed (positive attitude, bounce back)
-Lack of communication and teamwork contribute to up to 80% of sentinel events occurring in the operating room (e.g., wrong side, transfusion error)
What is the largest identifiable and preventable cause of accidents?
Fatigue
What are the acute and chronic effects of stress?
Acute: fight/flight/freeze
Chronic: r/t conditions in the workplace and individual reaction over a period of time
Stress is linked to accident involvement.
-The effects of stress on behavior are generally the most readily observable by work colleagues.
Communication issues and breakdowns in communication have been estimated to contribute between ___ and _____% to the development of critical incidents.
Communication issues and breakdowns in communication have been estimated to contribute between 15% and 67% to the development of critical incidents.
Define handoffs?
The real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of patient care.
