Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are returning to our coverage of the International Conference on Anesthesia Patient Safety 2024. This conference was sponsored by the JSA, JFA, APSF, and the ASA. This podcast series is bringing you insider coverage of the event. We hope that you have checked out episodes #190 and 191 for the first two episodes in our ICAPS series. We are back for the third episode in this series today.
Before we dive into the episode today, we'd like to recognize Masimo, a major corporate supporter of APSF. Masimo has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Masimo - we wouldn't be able to do all that we do without you!"
The next session, “Anesthesia Professionals’ Role in the Perioperative Care Environment, Implementation of the ASA’s Perioperative Surgical Home, addresses the APSF’s Patient Safety Priority of Clinical Deterioration.
Let’s jump into the session with speaker Tomohiro Sawa and the talk “JSA-Perioperative Information Management System and Nationwide Anesthesia Case Registries – A 30 Year Journey Towards Patient Safety and Quality Improvement.” The JSA developed the perioperative information management system for case registry and incident reporting that was built into the electronic health record. This was a huge success for developing a database for all anesthesia cases with the goal to promote patient safety during surgery and anesthesia. This system provides granular data to be able to further our knowledge on patient safety and outcomes. Going forward, there are important considerations for using this data: promotion of interoperability of the data, standardization of quality measurement indices, and international benchmarking by utilizing other perioperative databases.
Next up, we have Elizabeth Rubello speaking about “Medication Error Reduction in the Perioperative Period: Gaining a Better Understanding of Safe Medication Practices.” Medication safety is a critical threat to anesthesia patient safety and remains a common event. Rubello provides some important background information and considerations for improved medication safety going forward.
Did you know that in the United States, 7-9,000 patients die from medication errors every year? These preventable errors are associated with high costs and significant risks to patients. In 2022, the WHO World Patient Safety Day was dedicated to medication errors and working to improve medication safety.
Let’s look a little closer at these events which occur with a frequency of 1 in 20 administrations. Keep in mind that the observed error rates are higher than self-reported rates. Types of medication error include the following:
Incorrect dosing
Substitution
Contraindicated drug administration
Timing errors
Incorrect dosing and substitution are the most common.
The data for medication errors in Japan reveals the following: Of the 541 cases, 31% were incorrect dose, 28% were incorrect drug, omitted medication occurred in 16%, and contraindicated medications were administered at 6%.
Medication safety must be a priority for anesthesia professionals since we are responsible for all phases from deciding to give a medication to administration to evaluation for drug effect and side effects. The administration phase is the most common time when errors occur, and this is also the phase associated with the greatest harm.
Criminalization of medical error occurred in the United States when a nurse administered vecuronium in place of versed or midazolam due to a drug substitution error. The nurse was convicted and sentenced for up to three years’ probation. The APSF believes that criminal prosecution of healthcare professionals will make the work of preventing harm more difficult. For more information, check out the APSF’s “Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.” I have included the link in the show notes.
We are going to turn our attention to anesthesia safety tools and the application to medication safety. Have you performed a machine check today on your anesthesia machine? This helps us to provide safe anesthesia care, but what about medications. Most of the time there is no dose checking, no alarms, no way to detect errors, no exhaled propofol monitor. It is no surprise that medication errors occur as frequently as they do. Feedback and constraints can help improve medication safety. Feedback systems include color-coded syringes, barcode scanners, labels, two-provider checks, checklists, and alarms. There are many feedback systems used in operating theatres around the world to help ensure medication safety. Constraints are systems that help to prevent errors by not allowing that error to occur. These systems include smart pump guardrails, standardized concentrations, prefilled syringes, and standard layouts. Using a failure mode and effect analysis for prefilled syringes, 6 sub-steps are removed, and 19 possible failure modes are eliminated compared to drawing up medications for administration. Another important consideration is variance which allows the potential for an error to occur resulting in patient harm. Medication concentration standardization decreases variance, and the ASA has advocated for standardization of insulin, epinephrine, norepinephrine, phenylephrine, heparin, ketamine, dexmedetomidine, hydromorphone, lidocaine, and remifentanil.
We are going to run through several more important considerations for medication safety now.
· Labeling medications. There are two different sources of labeling: The manufacturer syringes with the total strength over the total volume and compounding facilities pre-filled syringes with the concentration in one ml. This is the preferred label method by anesthesia professionals since this avoids the mathematical error.
· Infusion pumps. It is a team effort to standardize pumps at local facilities so that the pumps are the same throughout the hospital and to use appropriate guardrails and alarms.
· Look-alike vials and ampules. And this may be increasing with drug shortages and sourcing medications from different manufacturers. For an example of this threat, tranexamic acid has been administered in place of bupivacaine during spinal anesthesia. In 20 reported cases, 10 patients died and there are additional recent cases being reported as well. Plus, there is a call to action for all of our listeners, when you see look-alike vials in your operating room, take a picture and submit it to the APSF look-alike vials gallery.
Going forward, recommendations for improved medication safety include
· Optimize the use of pre-filled syringes and infusions
· Utilize point of care electronic scanning for barcoding prior to administration
· Continue to work with regulatory agencies to standardize vials and standardize concentrations
For anesthesia professionals, it is important to think about how you can implement constraints in your practice, understand the constant risks in the perioperative environment, and maintain vigilance. Mark your calendars for 4-5th September 2024 and the APSF Stoelting Conference on “Transforming Anesthetic Care: A Deep Dive into Medication Errors and Opioid Safety.”
The next speaker is Jeong-Hyun Choi to talk about “The Current Status of Early Recovery After Surgery Implementation and the role of the Patient Safety Committee in Korea.” Currently, ERAS is in the early stages in Korea with implementation of ERAS for gastric surgery with variable adoption of ERAS principles and protocols. There has been increased compliance over the past few years. Barriers for adoption of these perioperative models include lack of manpower, poor communication and collaboration, resistance to change, and patient factors. For ERAS guidelines specifically, barriers include guidelines not available for all surgical procedures, delays in updating protocols, and not optimized for individuals. Important work has been done by the patient safety committee within the Korean Society of Anesthesiologists to promote evidence based medical practices that decrease variability and improve patient safety with clinical practice recommendations and practice standards. Check out the newly published, “Korean clinical practice guidelines for diagnostic and procedural sedation,” which offers multidisciplinary evidence-based recommendations for anesthesia professionals and non-anesthesia professionals for safe and effective moderate sedation at medical institutions. I will include the citation in the show notes as well.
We are highlighting one more talk today. It is “PSH Implementation in Japan: Perioperative Management Center” by Hiroshi Morimatsu. Perioperative management for patients in Japan is critical given the combination of shortages of anesthesiologists, increased number of surgical procedures, and number of elderly patients requiring care. Once the decision has been made to have surgery, that is when the team should start to support and optimize patients. The Perioperative Management Center includes a team of the following specialists: surgeon, anesthesiologist, nurse, medical engineer, physiotherapist, nutritionist, pharmacist, dentist for improved oral hygiene, and the patient in the center. The preoperative phase includes evaluation and instruction by the nurse, anesthesia evaluation, consent, and consult; prehabilitation by the physiotherapist, medication instructions, evaluation and treatment by dentist, and instructions by nutritionist. Currently, the center sees about 7,000 cases each year, but is limited by lack of manpower, money, and time. Plus, it is hard to demonstrate an effect on mortality and other patient safety outcomes. There is a call to action for anesthesia professionals to be leaders of the perioperative team in order to help keep patients safe from the moment the decision is made to have surgery.
Before we wrap up for today, we are going to hear from the chair of the conference.
[Yorozu] “Hi, my name is Tomoko Yorozu, and I am professor of Department of Anesthesiology, Kyoto University School of Medicine in Tokyo, Japan, and chair of International Conference on Anesthesia Patient Safety 2024 held in Tokyo last February.”
[Bechtel] Let’s take a listen as Yorozu shares important takeaways from the conference and what she hopes to see going forward.
[Yorozu] “While advancements in anesthesia methods and technologies appear to have enhanced patient safety, it is imperative to remain vigilant as new challenges may arise. The pursuit of anesthesia patient safety is an ongoing endeavor. That demands sustained commitment. Key takeaways include the importance of fostering a culture of safety, facilitating effective communication, and fostering teamwork within anesthesia practice.
I believe that the collaborative exchange of ideas among both domestic and international participants at ICAPS 2024 marks the milestone for anesthesia patient safety worldwide.
Through APFF's initiative to translate the newsletter, we have the opportunity to disseminate the APFF's top 10 priorities for anesthesia patient safety. Notably, the first priority, culture of safety, inclusion, and diversity, resonates strongly with the ethos of and caps. 2024. We view. I kept 2024 as the initial step towards deeper collaboration among American societies worldwide by establishing counterparts to the APFS in each country.
We can create a unified platform for ongoing discussions and initiatives focused on anesthesia patient safety management on a global scale. This collaborative approach brings us closer to our shared aspiration, encapsulated by the APFS core principle. No patient should be harmed by anesthesia.”
[Bechtel] Thank you so much to Yorozu for contributing to the show today and all of your work to bring us this amazing conference.
There are still so many more excellent talks from the conference and more ways to keep your patients safe, no matter where you are in the world. Mark your calendars for next week as we continue this series.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
The APSF podcast is intended for anesthesiologists, anesthetists, trainees, clinicians, and other professionals with an interest in anesthesiology, and patient safety advocates around the world. The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2024, The Anesthesia Patient Safety Foundation