Depth of anesthesia monitoring: an argument for its use for patient safety.

PURPOSE OF REVIEW: There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety. RECENT FINDINGS: We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward. SUMMARY: There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.

Beyond adverse events in anesthesiology: 'unanticipated events' and strategies for improved reporting.

PURPOSE OF REVIEW: Patient safety in anesthesiology has advanced significantly over the past several decades. The current process of improving care is often based on studying adverse events (AEs) and near misses. However, there is a wealth of information not captured by focusing solely on these events, potentially resulting in missed opportunities for care improvements. RECENT FINDINGS: We review terms such as AEs and nonroutine events (NREs), and introduce the concept of unanticipated events (UEs), defined as events that deviate from intended care that may/may not have been caused by error, may/may not be preventable, and may/may not have caused injury to a patient. UEs incorporate AEs in addition to many other anesthetic events not routinely tracked, allowing for trend analysis over time and the identification of additional opportunities for quality improvement. We review both automated and self-reporting tools that currently exist to capture this often-neglected wealth of data. Finally, we discuss the responsibility of quality/safety leaders for data monitoring. SUMMARY: Consistent reporting and monitoring for trends related to UEs could allow departments to identify risks and mitigate harm before it occurs. We review various proposed methods to expand data collection, and recommend anesthesia practices pursue UE tracking through department-specific reporting interfaces.

Patient Falls in the Operating Room: Why Is This Still a Problem in 2024?

ABSTRACT: Despite advances in patient safety, perioperative patient falls continue to be a persistent and preventable harm. Patient falls in procedural areas have been associated with multiple postoperative complications such as additional falls, functional decline, and hospital readmissions. Although fall-related databases exist, the specific number of periprocedural falls is difficult to ascertain, and the causes of such falls also remain elusive. We explore various solutions and recommend the creation of a national, focused database of periprocedural falls that will allow institutions to track numbers of falls in patients receiving anesthetic care and to identify the most common etiologies to enable the implementation of targeted strategies to prevent falls. Lacking this, we suggest specific screening and procedural recommendations during all phases of anesthetic care to increase providers' awareness and vigilance surrounding patient falls.

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture.

ABSTRACT: Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

Wiretap laws and the perioperative physician - The current state of affairs.

BACKGROUND: Wiretapping laws generally govern the legality of surreptitious or unconsented audio recording or other interception of face-to-face conversations, telephone calls, and other oral or wire communications. Many of these laws were originally passed in the late 1960s or 70s, and many have since been modified or amended. Wiretap laws vary from state to state within the United States, and many clinicians as well as patients are often unaware of the scope and implications of these laws. CASE EXAMPLES: We provide three hypothetical case examples to illustrate scenarios in which wiretapping laws come into play. METHODS: Through a review of current legislation, we compiled relevant wiretapping statutes for each state, as well as the potential civil remedies and criminal punishments that could be imposed for violations. We include the results of targeted research related to cases in which rights or claims under applicable wiretap statues have been asserted in the context of medical encounters and healthcare practice. RESULTS: We classified thirty-seven out of 50 states (74%) as one-party consent state laws, nine out of 50 states (18%) as all-party consent state laws, and the remaining four states (8%) as "Mixed". Remedies and punishments for violations of state wiretapping laws generally can involve civil or criminal fines and/or potential incarceration. Cases in which healthcare practitioners have asserted rights under wiretap laws remain rare. CONCLUSIONS: Our findings demonstrate heterogeneity with regard to the wiretapping laws state-to-state. The majority of punishments for violations involve fines and/or potential incarceration. Given the wide variability in state legislature, we suggest that anesthesiologists know their state's wiretapping law.

An inherently dangerous fluid warmer design.

A Hotline® fluid warmer is a device commonly used by anesthesia providers in the operating room to warm and infuse blood products and large fluid volumes. The purpose of the fluid warmer is to counter heat loss, which occurs under anesthesia. Despite normal checks performed prior to its use, we discovered a breach in the fluid warming set attached to the Hotline® fluid warmer during blood administration. The breach contaminated the patient's sterile intravenous line. We describe the quality and safety processes we undertook in detail. We discuss the notion that monitoring alarms are an important safety feature of most modern devices utilized by anesthesia providers. We believe the Hotline® fluid warmer lacks a crucial monitor for detecting a breach within the fluid warming set, and therefore recommend the addition of an alarm to improve this device's safety.