1. Preventing Operating Room Disasters Before They Happen Boston University School of Medicine May 5, 2005 Rafael Ortega, MD Associate Professor of Anesthesiology 1 st Annual Ellison Pierce Symposium Positioning Your Anesthesia Practice for the Future 9:30 AM – 10:00 AM

2. Objectives To review conditions O.R. disasters have in common To recommend strategies to minimize O.R. mishaps To present examples of O.R. disasters (or near disasters)

3. Anesthesia Risk The rates of morbidity and mortality depend on the definitions. Data demonstrates that risk directly attributable to anesthesia has declined over time.

4. Liquid Oxygen Leak Birmingham, Alabama VA Hospital Schumacher SD et al. Bulk Liquid Oxygen Supply Failure. Anesthesiology. 2004;100:186-189.

5. Recognition, management, and prevention of specific operating room catastrophes Presented at the American College of Surgeons 89th Annual Clinical Congress, Chicago, IL, October 2003. Christopher R. McHenry MD, Ramon Berguer MD, FACS, Rafael A. Ortega MD Journal of the American College of Surgeons Volume 198, Issue 5, May 2004, Pages 810-821 It’s Everyone’s Business!

6. Potential Crises Anaphylaxis Transfusion Reactions Malignant Hyperthermia Difficult Airway Fires Electrical Safety Cardiac Arrest Etc. But what do they have in common?

7. Features in Common Critical incidents Reason’s Swiss Cheese Relatively Rare Training (and re-training) Required Fixation Errors Reportable Litigation Prone More…..

8. Normal MP l Small jaw MP ll Small jaw Short neck MP lll Small jaw Short neck Obese Goiter MP lV …more preparation needed…

9. Preparedness Complexity match riskwaste

10. Organizational Influences Unsafe Supervision Precondition for Unsafe Acts Unsafe Acts Successive Layers of Defenses Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

11. Failed or Absent Defenses Aligned Holes Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

12. System Failure Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

13. What is a “Critical Incident”? Term made famous by Cooper. Defined: occurrences that are “significant or pivotal, in causing undesirable consequences. Also defined as: an event that led, or could have led to a problem. Critical Incidents provide opportunity to learn about factors that can be remedied. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.

14. What is the Role of Simulation? Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992: 63: 763-770 Holzman RS et al:. Anesthesia crisis resource management: real-life simulation training in operating room crises. Journal of Clinical Anesthesia. 7(8):675-87, 1995: >50% felt it should be taken once every 12 months Ziv A et al: Simulation based medical education: an opportunity to learn from errors. Medical Teacher. 27(3):193-9, 2005 May. Berkenstadt H et al: The feasibility of sharing simulation-based evaluation scenarios in anesthesiology. Anesthesia & Analgesia. 101(4):1068-74, 2005 Oct. Ziv A et al: Simulation-Based medical education: an ethical imperative. Academic Medicine. 78(8):783-788, 2003.

15. 21 September 2005. JetBlue Flight 292 What is the Role of Simulation?

16. Illustrative Examples Airway Management – Fixation Error Wrong Gas Administration Anaphylaxis Malignant Hyperthermia Fires

17. Losing the Airway 27-years-old male patient Fracture jaw Naso-tracheal intubation Class I visualization Difficult ventilation Equivocal capnogram Severe bronchospasm?

20. Fixation Errors Human errors (1/3 of error: FIXATION) DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg. 1990 Jul;71(1):77-82. Equipment failures >

21. Fixation Errors Types and Countermeasures "This and only this!" "Everything but this!" "Everything is OK!" Persistent failure to revise a diagnosis failure to commit to definitive treatment of major problem Persistent belief that no problem is occurring Accept possibility that first assumptions may be wrong Rule out worst case scenario Artifacts are the last explanation for changes in critical values CountermeasureError TypeDescription Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2005)

22. Circular No. 60-22. Federal Aviation Administration Washington, DC

23. ANTI-AUTHORITY IMPULSIVITY INVULNERABILITY "Don't tell me what to do. The policies are for someone else." "Do something quickly-anything!" "It won't happen to me. It's just a routine case." Follow the rules. They are usually right Not so fast. Think first. “It could happen to me. Routine cases develop problems." MACHO RESIGNATION "I'll show you I can do it. I intubate anyone’s trachea." "What's the use? It's out of my hands." Taking chances is foolish. Plan for failure “I'm not helpless. I can make a difference” Hazardous Attitudes and their Antidotes Attitude Example Antidote

24. Wrong Gas: a rare event

25. Compressors Coolers/Dryers

26. Wrong Gas: a rare event TanksValves Backup System

27. Incidents with Gases Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube. Eur J Anaesthesiol. 2000 Jul;17(7):456-8. Oxygen contamination of the nitrous oxide pipeline supply. Anaesth Intensive Care. 1998 Apr;26(2):207-9. Failure of operating room oxygen delivery due to a structural defect in the ceiling column Masui. 2000 Oct;49(10):1165-8. Pollution of the medical air at a university hospital in the metropolitan Tokyo area. Journal of Clinical Anesthesia. 14(3):193-5, 2002. Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device. Annales Francaises d Anesthesie et de Reanimation. 15(5):683-5, 1996. Contamination of the medical air supply with oxygen: a clinical engineering incident investigation. Journal of Clinical Engineering. 15(4):295-300, 1990. Medical air contamination with oxygen associated with the BEAR 1 and 2 ventilators. Critical Care Medicine. 16(4):362, 1988.

28. Fixation: Everything is OK Patient complaining of pain Free air the abdomen Cost center discrepancies

29. Anaphylaxis Forty-two anaesthetists in teams of two attended training sessions with a critical incident of anaphylactic shock in a full-scale simulator. None of the teams made the correct diagnosis within 10 min and treatment according to the treatment sequence was not initiated. Only 6/21 teams considered the right diagnosis only after hints from the instructor 15 min after the start of the incident. Conclusion: Anaphylactic shock was difficult to diagnose and no structured plans were used for the treatment in the simulated incident in this study. Jacobsen J, Lindekaer AL, Ostergaard HT, et al. Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator. Acta Anaesthesiol Scand 2001 (Department of Anaesthesiology; Section of Simulation; Herlev Hospital; DK-2730 Herlev; Denmark)

30. Drugs Involved in Perioperative Anaphylaxis Data from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395 12% 8% 4% 3% 1% 3% 69% Muscle Relaxants Latex Antibiotics Hypnotics Colliods Opioids Other

31. Treatment of Perioperative Anaphylaxis from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395

32. Modified from: Hepner: Anaphylaxis during the perioperative period. Anesth Analg, Volume 97(5).November 2003.1381-1395 Treatment of Perioperative Anaphylaxis

33. Malignant Hyperthermia

35. Dantrolene 20mg/ampule 60 cc’s of sterile water Dose: 2.5mg/kg (1mg/lb) 100kg patient = 10 ampules

37. A. Line Infection Ortega R, Rengasamy SK, Lewis KP: Infection after radial artery catheterization. Anesth Analg 2002;95:780-7

38. Amyloidosis

39. Compartment Syndrome

40. Impalement of the Brain

41. Broken Needle in Aorta

42. Ventilator Failure Ortega RA, Vrooman B, Hito r: Another Cause for Ventilator Failure. Anesthesiology. Accepted for publication Jan 2006

43. Fire Ortega RA: A Rare Cause of Fire in the Operating Room. Anesthesiology. 89(6):1608, December 1998.

44. The Fire Triad Fire Triad Ignition Source Fuel Oxidizer

45. MAC EDITORIAL MAC Should Stand for Maximum Anesthesia Caution, Not Minimal Anesthesiology Care Hug CC: Anesthesiology: Volume 104(2) February 2006 pp 221-223

46. Closed Claims Injury and Liability Associated with Monitored Anesthesia Care: A Closed Claims Analysis Bhananker SM, Posner KL, Cheney FW, Caplan RA et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

47. Mechanism of Injury Bhananker SM et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

48. Fires Bhananker SM et al: Anesthesiology: Volume 104(2) Feb 2006 pp 228-234

49. MAC: Take Home Message Least qualified anesthetist assigned Diligence often less by anesthetist and surgeon History of safety (Resting On Your Laurels) Limited pre-anesthetic evaluation Surgeons may explain MAC as: “a nap” Competing goals: surgeon/anesthetist/patient Head and neck procedures: conflict with airway Antiseptic solutions disguise skin color changes Head and trunk draping reduces respiration visibility

50. MAC: Take Home Message Monitor displays poor visibility Audible monitor signals drowned out by music/noise Impeded Auscultation of heart and lungs Personnel inexperienced in resuscitation techniques Oxygen delays Hgb desaturation while CO2 rises Drug effect onset ≠ peak effect Failure to check anesthesia/resuscitative equipment Oxygen and nitrous oxide are oxidizers.

51. Administrative Guidelines for Response to an Adverse Anesthesia Event Journal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Feb www.APSF.org Primary anesthetist concentrates on continuing patient care. Notify a physician responsible for supervision of anesthesia activities Sequester equipment Contact the hospital Risk Manager immediately anesthesiologist and other individuals document relevant information After discussion with the incident supervisor, write on medical record relevant information about what happened and actions taken Complete and file incident report as soon as practical State only facts. Do not use judgmental terms Consult early and frequently with the surgeon. Immediately call other consultants who may help improve long term care

52. The End