Anesthesia is about more than just “pushing drugs”. It is about being an advocate for your patient from the moment it arrives for an anesthetic procedure, throughout the anesthetic period, and even after the patient is home with their family. This means not only ensuring that the patient survives anesthesia but doing the absolute best during the peri-anesthetic period as is possible.
Historically, documented errors related to anesthesia (primarily coming from human literature) are quite low, whereas errors related to surgery are very high. The accuracy of this literature is quite questionable as much of the data collected relies on self-reporting of errors and there are inherent and obvious issues with that. What we do know is that checks and balances in human hospitals are significant and still the rates of reported errors that occur are staggering. In the veterinary field, those checks and balances are few, comparatively. Even in the most efficient and high-quality veterinary hospitals, those checks and balances that do occur in other areas of the hospital, are often even more limited in the operating room. In the operating room not only are there generally fewer checks and balances but the technical staff are often put in a position to provide more than just anesthetic care (e.g. run for instruments, take front desk or client calls, etc.), increasing the lack of attention and distractions from their focus on anesthesia. It is not uncommon for these staff members to feel they must put patient care aside to please clients and clinicians, which can result in significant patient safety concerns. Additionally, there are people of varying educational backgrounds and experience rotating care of these patients. Many of the safety measures implemented in human medicine are not feasible for many veterinary hospitals due to the cost and lack of appropriate staffing (e.g. purchase of prefilled syringes per patient, barcoding of medical supplies, a surgical and anesthesia technician per case, etc).
There is much evidence to suggest that in order to decrease the risk of errors in the peri-anesthetic period you must first identify what errors are occurring, how often, and why. Second, solutions to minimize these risks should be designed and implemented, and finally, follow-up measures to assess the reduction of error rates. Identifying what kind and how often errors are occurring becomes difficult in the operating room. The difficulty lies in both the lack of checks and balances and in the fear of repercussions for making and admitting to said error. Much of the research done on the human side, strongly supports the notion that a non-punitive process of error reporting not only increases the identification of errors but improves both the ability to improve overall patient care and correct the correctable measures, minimizing these risks. Lastly, some lack of reporting occurs when an individual does not recognize an error was even made, chooses not to say anything because they feel it was not “a big deal” or feel that reporting it will not make a difference either way.
Errors occur in two broad categories; active failures or systemic failures. Active failures are said to be associated errors of the individual, whether that is due to inattention to detail, forgetfulness, carelessness, negligence, etc. Systemic failures are faults in the institution or organization. This category acknowledges that no human is infallible, so the conditions in which the person works increase or decrease the risks of errors occurring. Factors that affect systemic or organizational success are communication, leadership, area organization, staffing, support of staff, etc. Regardless of the category, the end result of failure in either category is the same, poor patient care, dissatisfied clients, profit loss, and legal ramifications.
Active failures can be of an unintended nature or of a willful or deliberate nature, though the latter is uncommon. Unintentional errors can occur for a variety of reasons, such as not performing an exam of a patient prior to anesthesia, poor memory, fatigue, stress, haste, interpersonal conflicts leading to poor communication, poor hearing or eyesight, lack of knowledge or skill, attempting to multitask, poor decision making and so on. Persons that choose to purposefully depart from acceptable practice, bend the rules, lie or choose not to improve their skill or knowledge base are often those that cause harm from a willful or deliberate choice to put aside patient care. These can lead to medication errors, medical mistakes (e.g. pop-off valve left closed), not having appropriate monitoring equipment or realizing too late the equipment is not working, etc. Almost all the errors associated with active failures are avoidable.
Systemic failures are the organizational influences that predispose errors to occur. These are most often related to poor communication. Lack of communication amongst all involved staff members is the number one contributor to systemic failure and peri-anesthetic errors. Poor leadership and lack of appropriate training of staff members, poor technician oversight, poor relationship with staff inhibiting them from “hearing” what you are saying, all lead to increased incidence of medical errors. Environmental factors can play a role, as well. For example, poor lighting, disorganization of supplies, unfamiliarity with the room/supply layout, clutter, distractions, poor equipment care, etc. Other contributors are the push for productivity over patient care, lack of breaks for the staff, allowing or expecting overtime, etc. Again, almost all of these are avoidable.
So, what is the solution?
It starts with recognition and an open-door policy for reporting errors that occur, and allowing for a non-punitive approach to errors that occur unwilfully. Second, providing appropriate staffing to allow for and enforce breaks for staff throughout the day. Providing appropriate oversight and training to new employees. This may include quizzes or open discussion rounds to make sure that concepts are clearly understood. Avoid rotating staff that are unfamiliar with or uncomfortable with anesthesia without appropriate support and oversight. Meet with your staff regularly to find out what their perspective is and what ideas they have for improvement. Encourage teamwork and resolution of interpersonal conflicts, for the betterment of patient care and for the improvement in day-to-day work environments. Organize anesthetic and surgical areas and label drawers. If there are multiple rooms, organize all the rooms the same. Minimize routing reorganization of areas. Label ALL syringes, even if you have just drawn it up and are about it to give it. Pause and read labels for all drugs before administering them. Have the owner mark the surgical site on the patient, on an admission form, and have the surgeon confirm. Restrict computer use and phones in the OR (work and personal) unless for emergency contact. Encourage efficiency without rushing technical staff. Be prepared ahead of time so that there is minimal extra-anesthetic work that needs to be done after the patient is anesthetized. And most importantly, communicate!
Communication is key.
This starts with either morning rounds about anesthetic cases for the day or pre-induction rounds. In human medicine, they are called “Time Outs”. All persons involved in the surgery/anesthesia of that patient “round” at once to discuss the procedure, supplies needed, patient concerns, and potential anesthetic or surgical complications possible or expected. Pre-induction Checklists have been implemented in the human field after studies done by the World Health Organization showed a significant decrease in morbidity and mortality with their use. Checklists assure that all necessary diagnostics are done, needed supplies are known, any potential risk factors are discussed and prepared for ahead of time. They also assure that important intraoperative tasks are completed before the surgery is completed (e.g. sponge counts). The checklist can also be used to assure that a client is called postoperatively, that those recovering the patient have been fully rounded, that samples are submitted, etc. It’s not just checking off a box that decreases complication rates, it’s the assurance that those tasks have actually been performed that decreases the rate of errors and mistakes. It is also a way of improving communication. “The number one way of preventing errors is engagement of the entire surgical team across the perioperative process.”
This will always be a work in progress. Errors will inevitably occur but by implementing these tasks, not only will you improve patient care, client satisfaction, and hospital reputation; you will improve the environment for you and your staff, assuring minimal turnover and amazing teamwork. Please reach out to me if you would like a checklist to start with or an example to build off of.
Hofmeister, EH, Quandt, J, et al. “Development, implementation and impact of simple patient safety interventions in a university teaching hospital” Veterinary Anaesthesia and Analgesia 41: 243-248 (2014)
Ludders, JW, McMillan, M. Errors in Veterinary Anesthesia Oxford: John Wiley & Sons, Inc., 2017
Merry, AF, Anderson, BJ. “Medication errors – new approaches to prevention” Pediatric Anesthesia 21: 743-753 (2011)
Nanji, KC, Patel, A, et al. “Evaluation of Perioperative Medication Errors and Adverse Drug Events” Anesthesiology 124(1): 25-34 (2016)
Oxtoby, C., Ferguson, E. et al. “We need to talk about error: causes and types of error in veterinary practice” Veterinary Record (2015) Web
Ugur, E, Kara, S, et al. “Medical errors and patient safety in the operating room” J Pak Med Assoc 66(5):593-7 (2016)
Wahr, JA, Abernathy III, JH, et al. “Medication safety in the operating room: literature and expert-based recommendations” British Journal of Anaesthesia, 118(1): 32-43 (2017)