Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

OBJECTIVES: The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact. METHODS: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018. RESULTS: The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events. CONCLUSIONS: This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions. METHODS: RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes. CONCLUSIONS: This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Factors influencing oxygen store during denitrogenation in the healthy patient.

STUDY OBJECTIVE: To define the various factors that influence the rate of effective preoxygenation. DESIGN: Prospective, randomized study. SETTING: Procedure room in a teaching hospital. SUBJECTS: 14 ASA physical status I volunteers who performed 4 sessions of breathing in random order. Of these volunteers, 7 performed two extra sessions using vital capacity breathing, which were also completed in random order. INTERVENTIONS: Using the circle system, volunteers breathed with a mouthpiece and nose-clip until expired nitrogen reached 5%, using either a fresh gas flow of 5 L/min or 10 L/min or a system flushed with O(2). MEASUREMENTS: End-expired levels of O(2), nitrogen, and CO(2) were recorded. MAIN RESULTS: Minute ventilation, functional residual capacity, and age were significant factors for rate of denitrogenation. However, height and weight were not significant factors in predicting time to denitrogenation. At low flow rates, flushing with O(2) significantly decreased the time of denitrogenation. There appeared to be little clinical benefit of flushing with O(2) when a 10 L/min O(2) flow was used. CONCLUSIONS: A high gas flow rate appears critical to achieving rapid preoxygenation.