Safety is in the details
Safety in the ICU

5 Mistakes in Anesthesia and How to Avoid Them

September 4, 2016

 

Nearly 40 million anesthesia procedures are conducted each year in the USA [1]. The ability to administer anesthesia is one of the great achievements of modern medicine. However, as with any medical process, there is always potential for error.

251,000 people in the USA die annually due to medical errors, making medical errors the 4th most common cause of death in 2013, after cancer and heart disease [2]. Medical errors are divided into medication errors, Advert Drug Events (ADEs), near misses, slips and lapses, according to severity [3]. There are 1.5 million ADEs each year in the US according to the IOM [4]. 5.3% of (ADEs), an event in which a patient is harmed or injured due to interventional drugs, are found in pre-operation settings [5]

Fortunately, hospital administrations and their staffs are working diligently to eliminate the mistakes involved with anesthesia to prevent errors from occurring in the first place. Through a combination of safety protocols, changes in medical processes, and improvements in medical technology, patients face less risk than ever before.

The following are five common mistakes in anesthesia and how they can be avoided.

1. Medication dosing errors

Medication dosing errors are an ongoing concern in hospitals and occur most frequently in the middle of anesthesia [7]. The three most common causes of medication dosing errors were found to be:

• Inadequate experience (16%)
• Inadequate familiarity to equipment or device (9.3%)
• Haste, inattention, or carelessness (all tied at 5.6%)

It's important for hospitals to encourage staff to speak up whenever they are unsure about medication dosing or with medical equipment.

2. Unintentional administration of residual anesthetics 

Traditional stopcocks have dead space that increases the risk of delivering anesthetic drugs and infection from built-up residue into the patient’s veins during the flushing of the device. Risks of accidental flushing of drugs through IV are higher for children, which some experts believe is underreported.

3. Ineffective Post- op pain management

Although hospitals know the best methods for managing pain preoperatively – finding an ideal solution for postoperative pain management remains a challenge. Healthcare professionals have to strike a balance between controlling postoperative pain and minimizing opioid-related adverse effects.
Poor timing of drug administration increases vomiting, nausea infections, and the likelihood of developing chronic regional pain syndrome.

Now more hospitals are moving away from a computerized pump and patient-controlled analgesia, which is prone to side effects. Instead, hospitals are making use of regional anesthesia, such as doing a spinal anesthetic with peripheral nerve blocks, local infiltration of analgesia or both.  The results are a decrease in potential side effects and increase in patient satisfaction.

4.  Documentation errors

Errors with documentation of anesthesia are one of the more common mistakes made in hospitals. However, documentation errors tend to cause more issues with billing than they do for the safety of the patient.

Common documentation errors include:
• Completing the Surgical Procedure(s) section of a patient's anesthesia record before the surgery is finished
• Unclear documentation stating  the primary purpose of postoperative pain management
• Surgeon's documentation of request for postoperative pain management

While these errors cause more problems for billing, hospitals have a high demand for efficiency in all areas of their organization. Hospitals should consider processes that ensure documentation is performed by the right people at the appropriate times – not only for proper anesthesia administration but to keep everything well-organized.

According to the Journal of the American Society of Anesthesiologists Inc. a 21.8% reduction of ADEs is possible by using the multimodal system for anesthesia [5]. A trial conducted in the medical faculty of the University of Auckland, New Zealand in 2011 shows this system can be clearly associated with reduced errors [8] .

5. Not controlling IV flow rate properly

Improper intravenous fluid regulation can result in serious complications for patients. It's critical that IV flow rates are accurately set, especially when administering anesthesia.

In most cases, fluid overload can cause a patient to have a headache, high blood pressure, anxiety, and trouble breathing. On the other hand, low flow can prevent a patient from reacting to the drug as needed.
 

Elcam’s Marvelous™ stopcock  uses a luer-activated valve to minimize the risk of fluid overload by reducing the need for stopcock manipulations. It also decreases medication errors due to drug interactions and unintentional administration of residual drugs by eliminating the need of post-medication flushing with a syringe.
 

“I really like MarvelousTM due to the self-flushing feature” says Joseph Baiton RN, Chief CRNA at Maricopa Medical Center in Pheonix Arizona USA. “It helps us ensure that medication is not left behind in the side port, medications are not mixed, and the patient is transferred to the PACU safely. We were using competitive products prior to MarvelousTM. The transition has been seamless and we have been very pleased with how the Marvelous TM performs”, he added.


Elcam’s new S2R connector reduces the chances for kinks in the IV line. Kinks can decrease the flow and thus affect drug administration. By using a rotating connector (which is also available in a stopcock configuration) nurses can be assured drug administration flow disturbances are reduced.


To learn more about Elcam’s Marvelous and other products, visit us at AANA Booth 1400, September 11 – 13 in Washington DC.

 

CONTACT US  to schedule a meeting at the conference.

 

Resources:
1. https://lh4.googleusercontent.com/-Zvng-8RHcxg/U61URFSq92I/AAAAAAAAAeQ/cMFdoiKyrbg/w1247-h2523/jtcomm-speak-up-anesthesia-infographic-final.jpg
2. https://1.bp.blogspot.com/-Grsgp5bHU4M/Vy8Z4pxScKI/AAAAAAAAnaY/c8Yt0zmCtzYgWBsCr2ZvBzDvtJ2VgdM2ACLcB/s1600/050416-MedicalErrors.jpg  and http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933474/table/T0001/
4. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx
5. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2476460
6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933474/table/T0002/
7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933474/
8. http://www.bmj.com/content/343/bmj.d5543.long


More reading recommendations:

Learn about the hazards involved with anesthetic residues in the IV line
Learn more about Marvelous – read our white paper
Compare Marvelous to standard stopcocks and see how much time it can save you!

 

 

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