Julia Neily1, Elda S Silla1, Sam John T Sum-Ping2,3,4, Roberta Reedy5, Douglas E Paull6,7, Lisa Mazzia6, Peter D Mills8,1, Robin R Hemphill6. 1. From the Veterans Health Administration (VHA) National Center for Patient Safety (NCPS), White River Junction, Vermont. 2. National Anesthesia Service, US Department of Veterans Affairs, Washington, DC. 3. Department of Anesthesiology and Pain Management, the University of Texas Southwestern Medical Center, Dallas, Texas. 4. Veterans Affairs North Texas Health Care System, Dallas, Texas. 5. Department of Anesthesiology, VHA, Seattle, Washington. 6. Veterans Health Administration (VHA) National Center for Patient Safety (NCPS), Ann Arbor, MI. 7. Georgetown University School of Medicine, Washington, DC. 8. Department of Psychiatry, the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Abstract
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.
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.
Authors: Karen C Nanji; Alan Forbes Merry; Sofia D Shaikh; Christina Pagel; Hao Deng; Joyce A Wahr; Adrian W Gelb; Beverley A Orser Journal: BMJ Open Date: 2020-06-30 Impact factor: 2.692