Integration of the Codonics Safe Label System® and the Omnicell XT® Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability.

Background: Perioperative medication errors are recognized as a source of patient morbidity and mortality. Medication management systems with built-in scanning and label-printing functions that integrate with medication-dispensing cabinets have the potential to decrease medication administration errors by improving compliance with medication labeling. Whether these management systems will also improve periodic automatic replacement (PAR) inventory control and be accepted by users is unknown. We hypothesized that implementation of the Codonics Safe Label System®, an automated labeling system (ALS), would increase compliance with labeling guidelines and improve PAR inventory control by decreasing medication discrepancies while maintaining user acceptability in the OR. Methods: We audited a cohort of anesthesia workstations and electronic anesthesia records for 2 months to compare dispensed and administered medications and establish a discrepancy baseline. We also observed a convenience sample of syringes to evaluate labeling compliance. Post-implementation of the ALS, we repeated the audit. Finally, an anonymous survey was distributed electronically to providers to assess user acceptability. Results: Pre-implementation the average daily medication discrepancy rate was 9.7%, decreasing to 6.1% post-implementation (χ2 1 = 43.9; P < .0001). Pre-implementation 330 of 696 syringes (47.4%) were either missing a label or labeling elements. After implementation, 100% of all syringes received a label with the complete required labeling information (P < .0001). All respondents agreed or strongly agreed that the system was easy to use, accurate, met their needs, printed labels quickly, improved safety and efficiency, and was recommendable. Conclusion: The ALS significantly increased the rate of best-practice-compliant medication labeling while reducing medication inventory discrepancies. The system was highly accepted by providers.

A Collaborative Partnership between the Multicenter Handoff Collaborative and an Electronic Health Record Vendor.

OBJECTIVES: The operating room is a specialized, complex environment with many factors that can impede effective communication during transitions of care between anesthesia clinicians. We postulated that an efficient, accessible, standardized tool for intraoperative handoffs built into standard workflow would improve communication and handoff safety. Most institutions now use an electronic health record (EHR) system for patient care and have independently designed intraoperative handoff tools, but these home-grown tools are not scalable to other organizations and lack vendor-supported features. The goal of this project was to create a standardized, intraoperative handoff tool supported by EHR functionality. METHODS: The Multicenter Handoff Collaborative, with support from the Anesthesia Patient Safety Foundation, created a working group of frontline anesthesia experts to collaborate with a development team from the EHR vendor (Epic Systems) to design a standardized intraoperative handoff tool. Over 2 years, the working group identified the critical elements for the tool and software usability, and the EHR team designed a standardized intraoperative handoff tool that is accessible to any institution using this EHR. RESULTS: The first iteration of the intraoperative handoff tool was released in August 2019, with a second version in February 2020. The tool is standardized but customizable by individual institutions. CONCLUSION: We demonstrate that work on complex health care processes critical to patient safety, such as handoffs, can be performed on a national scale through cross-industry collaboration. Frontline experts can partner with health care industry vendors to design, build, and release a product on an accelerated timeline.

The Use of Patient Digital Facial Images to Confirm Patient Identity in a Children's Hospital's Anesthesia Information Management System.

INTRODUCTION: Patient identification errors, albeit rare, continue to occur despite the implementation of the Universal Protocol. Researchers at a tertiary care children's hospital hypothesized that introduction of a digital photograph to the preanesthesia checklist would reduce wrong-patient charting and near-miss events around the induction of anesthesia. METHODS: In late 2014 a digital facial image obtained either on arrival to the preoperative preparation area or for inpatients, on admission to the hospital, was added to the initial verification screen (anesthesia sign-in) of the anesthesia information management system (AIMS). This verification process includes visual inspection of the patient's facial image and checking the patient's hospital ID bracelet for the patient's name, birthdate, and hospital number against the AIMS verification page. Wrong-patient charting and near-miss events were reviewed weekly by the electronic health record (EHR) perioperative team through analysis of AIMS records and through provider self-report to the institution's Anesthesia Incident Reporting System. RESULTS: Between January 1, 2015, and July 1, 2018, 95,146 patients (42,255 females; 52,891 males) were anesthetized in the hospital with only one instance of charting on the wrong patient in the AIMS. A Wilson score interval would give a percentage of 0.001% (95% confidence interval: 0.0002%-0.006%). Therefore, we are 95% certain that the true rate of charting on the wrong patient is below 1 in 16,794 patients. CONCLUSION: At the induction of anesthesia, the addition of a current digital facial image to the Universal Protocol may be useful in preventing misidentification and mischarting on the anesthetic record.

Threat and error management for anesthesiologists: a predictive risk taxonomy.

PURPOSE OF REVIEW: Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. RECENT FINDINGS: Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. SUMMARY: TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation.

Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department.

BACKGROUND: Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented. METHODS: An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system. RESULTS: A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago. CONCLUSION: An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.

Case report: epidural hematoma nine days after removal of a labor epidural catheter.

Timely recognition and surgical decompression are crucial to minimize risk of permanent neurologic deficit from epidural hematoma. We present the case of a patient who developed acute back pain, sensory deficit, and ascending weakness 9 days after removal of a labor epidural catheter. Magnetic resonance imaging revealed a heterogeneous fluid collection extending from C6-7 through the lumbar region, with cord deformity at T9-11. Decompression laminectomy was performed within 4 hours of symptom onset. Twelve hours later, her motor function had fully recovered. Subsequent anatomic and hematologic workup was inconclusive. This presentation is atypical given the delayed presentation of symptoms after epidural placement.

Effect of rotator cuff pathology on shoulder rhythm.

The purpose of this study was to test the hypothesis that shoulder rhythm is affected by rotator cuff pathology during arm elevation. We divided 42 subjects into 3 groups: those with full-thickness rotator cuff tears (RCTs) (n = 14), those with tendinopathy (n = 13), and control subjects (n = 15). Shoulder kinematics was recorded while subjects performed elevation in the sagittal and scapular planes. Euler angles were computed for scapular and humeral elevation. Data were divided into 3 equal phases. Lines were fit and the slope determined for each phase. Significant differences in slopes ( P < .05) were found between experimental groups for both motions. The RCT group had higher slopes in the initial and middle phases for sagittal elevation and in the middle phase for scapular abduction. The scapula was elevated more in the RCT group in the initial two thirds of movement. This motion may change the length of remaining muscles so that they operate on a more effective part of their length-tension curve.