Adverse outcome (N = 7,740)
% of claims
Median payment ($)
Range of payment ($)
Death
29
338,000
353–17,934,000
Nerve damage
19
92,650
394–10,716,000
Permanent brain damage
10
1,216,950
5,950–35,960,000
Airway trauma
7
72,000
34–2,115,000
Eye damage
4
97,600
37–3,335,000
Injury to newborn
3
667,069
3,966–15,822,000
Stroke
3
301,250
7,050–24,966,195
Pneumothorax
3
62,900
465–13,950,000
Back pain
3
26,400
2,240–1,782,500
Headache
3
18,300
884–874,500
Aspiration pneumonitis
3
301,750
573–3,450,000
Myocardial infarction
2
218,000
7,600–1,810,500
Burn, thermal
2
49,995
5,025–844,800
Skin reaction
2
21,788
488–727,500
Awareness
1
37,463
1,940–846,000
Meningitis
1
101,219
4,608–873,000
The publication of guidelines by the ASA for managing issues with high rates of adverse outcomes has led to a significant decline in these adverse outcomes (Table 31.2). For example, difficult airway management during induction of anesthesia has long been regarded as one of the most challenging issues in anesthesia patient safety. However, an analysis of claims associated with difficult airway management during induction of anesthesia shows a marked, statistically significant decrease in the incidence of death and brain damage (62 % vs. 35 %, p < 0.05) in the period after the publication of the ASA Difficult Airway Algorithm (1993–1999), when compared with period before the publication of the airway guidelines (pre-1993). The ASA Difficult Airway Algorithm has been reproduced in Appendix A.
Table 31.2
ASA Standards for Basic Anesthetic Monitoring
Standard 1: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care | |
Standard 2: During all anesthetics, the patient’s oxygenation, ventilation, circulation, and temperature shall be continually evaluated | |
Oxygenation | Oxygen analyzer for inspired gases |
Observation of the patient | |
Pulse oximetry | |
Ventilation | Auscultation of breath sounds |
Observation of the patient | |
Observation of the reservoir bag | |
Capnography (carbon dioxide monitoring) | |
Circulation | Continuous ECG display |
Heart rate and BP recorded every 5 min | |
Evaluation of circulation | |
Auscultation of heart sounds | |
Palpation of pulse | |
Pulse plethysmography | |
Pulse oximetry | |
Intraarterial pressure tracing | |
Temperature | Monitor temperature when changes are intended, anticipated, or suspected |
Challenges Facing the Anesthesia Provider
The operating room is a unique environment and presents challenges to even the most vigilant anesthesiologist. Environmental factors such as noise, multiple alarms, and continuous movement through the operating room of members of the team can all distract attention. Human factors like fatigue and sleep deprivation can also affect monitoring and cognitive tasks. In addition, with the emphasis on enhanced productivity, “production pressure” may force errors and compromise patient safety.
Automated information systems that provide automated anesthesia recordkeeping have become increasingly popular. They have been shown to be of great benefit in support of patient care and safety, and enhancement of clinical quality improvement programs. These systems are increasingly being implemented in various anesthesia departments to support a number of functions, including real-time clinical decision support.
Steps to Ensure High Quality Anesthesia Care and Patient Safety
In order to optimize patient safety and ensure high quality care, the following principles should be taken into consideration by the anesthesia practitioner.
1.
Make patient safety a priority. Be an advocate for your patient, always.
2.
Thorough planning . Follow the Boy Scout motto of “Be Prepared.” Practice meticulous preoperative planning, and formulate a plan for intraoperative as well as postoperative care. Have a back-up plan in mind. However, at times, it may not be possible to plan far ahead because of the unpredictable nature of the operating room environment. Even when under pressure, slow down, think things through rationally and clearly and formulate a plan of action.
3.
Vigilance. Monitoring the patient involves not only electronic monitoring but also astute clinical observation. Chest rise, mucus membrane color, furrowing of the brow are just a few signs that can provide a wealth of information about the patient. Be aware of what is happening in the operating room at all times, and keep an eye on what’s going on across the drapes. Listen out for indicators of potential problems like for the increasingly frequent sound of the suction catheter heralding an increase in blood loss.
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