ANESTHESIA PATIENT SAFETY FOUNDATION
NEWSLETTER

Volume 5, No. 1, pp 1-12
Spring 1990
Table of Contents

ASA Panel Examines Improved Anesthesia Mortality/Morbidity
Insurance Premiums Cut in New Jersey
New Jersey Continues as Center of Anesthesia Regulatory Activity
Features of Modern Anesthesia Machines
STA Announces first Annual Meeting: January in Florida
From the Literature: Handling an Anesthetic Related Death
International Committee for Prevention of Anesthesia Mortality and Morbidity to Meet in Warsaw in Fall
Letters to the Editor:
ASA Publishes Safety Information Brochure for Public
Notes




ASA Panel Examines Improved Anesthesia Mortality/Morbidity

Insurance Premiums Cut in New Jersey

by John H. Eichhorn, M.D.

Who deserves the credit for the recent improvements in anesthesia morbidity and mortality? This was the topic of a breakfast panel sponsored by the Society for Technology in Anesthesia last October at the ASA Annual Meeting.

Nine speakers and moderator N. Ty Smith, M.D., president of the society, discussed & proposition that anesthesia care is now safer and that specific factors can be cited as contributing to this improvement. Each speaker was assigned one factor to analyze. Many of them suggested that it was difficult or impossible to dissect out the role of any one factor, but that they would accept the assignment of advocacy for their specialty in the spirit of an intellectual exercise.

Monitors: William New Jr, M.D. of Nellcor Corp. noted that monitors am "many unsleeping eyes" that allow us to "see the invisible," especially early hypoxia and desaturation. He related that all anesthesia providers sometimes deal with hypoxemic patients, giving the monitoring concept significant clinical immediacy and a marketing advantage The positive aspect of monitoring is verifiable in both lab testing and clinical practice, according to Dr. New. In a light vein, monitors were referred to as "salvation in a box," with serious follow-up comments on how electronic monitoring is helping anesthesiologists take charge of their own clinical futures.

Educators: Susan L Polk, M.D. of the University of Chicago stated that monitors were not likely to be of any value unless the user can recognize and act on what he sees. She maintained that the essential elements of an anesthesia education are knowledge, skills, attitude, humbleness and fright. Also, Dr. Polk was the fast to question whether there really has been a reduction in mortality and morbidity. However, accepting that promise, she noted the often-quoted statistic that 70-80% of all anesthesia mishaps involve human error. Which practitioners have problems can be evaluated in fight of the impact of age, type and place of training, board certification status and tune in practice. Further, the definite general improvement of the quality of anesthesia residents can be expected to contribute to an eventual parallel improvement in anesthesia practice.

Concerning these trainees, Dr. Folk concluded by stating that anesthesia educators "are responsible for attracting and choosing the buffable and then buffing them.

The Clinicians: William K. Hamilton, M.D. of U.C. San Francisco opened with & observation that there are no "real" data on anesthesia outcome, so he is not sure there is improvement for which to take credit. He did state that he felt there has been a significant increase in the number and quality of people entering anesthesiology and that this should go credit (or blame). Improved residency education upgraded, longer, more material to W6 from, as well as evolution of the profession and & ability to learn from the mistakes of others contribute to better clinicians who we, by definition, the ones who are the instruments of improved clinical care

Standards: Frederick W Cheney, M.D. of the University of Washington spoke on anesthesia standards and their role in unproved care. He quoted a plaintiffs malpractice attorney who has said that he is simply not seeing anesthesia cases any mom Dr. Cheney felt that it was not the monitoring standards themselves but, rather, all the publicity surrounding them that attracted the attention of the average practicing anesthesiologist and eventually had an impact on him. Now, some years later, we are seeing the benefits "on the front fine" with fewer anesthesia catastrophes.

The Researchers: Jeffrey B Cooper, Ph.D. of the Massachusetts General Hospital noted that there must be research behind all progress and, therefore, referring to improved anesthesia practice, researchers should be credited with starting it all. He suggested them is "real data" in the form of reduced anesthesiologist malpractice insurance premiums to support the claim that anesthesia mortality and morbidity has improved. To the extent that new machines, new monitors and new drugs play a role in this progress, researchers come before the clinicians as trail blazers. Studies of human error highlighted the clinicians' fallability and made it more acceptable to try to address this issue. Standards followed and led to widespread conscientiousness-rising of all involved. Dr. Cooper stated that the "constant bubbling" of research is the hope for the future; research has to be supported. It is the first thing cut in a budget crunch, and this is totally inappropriate because of the consequent inability for practice to change and progress.

As an important aside, Dr. Cooper commented that the lawyers had to be given indirect credit for increased anesthesia safety because they precipitated an economic crisis that led to research and a subsequent cascade of positive events. The Anesthesia Patient Safety Foundation: E.C. Pierce, Jr., M.D., President of the APSF, recounted some of the four-year history of the Foundation. He described his own experience with a mishap. Overall, he opined, economics of medical care is an increasingly important driving force Dr. Pierce noted that he believed that the APSF is contributing to the unquestionable improvement in anesthesia care through various of its activities: from this Newsletter to educational sessions at meetings (such as the study booth in the ASA exhibit) and at its sponsored meetings (e.g. anesthesia simulators) to the safety research grants given by the organization. He stressed the need for support of the Foundation if all these efforts are to continue to contribute to improved anesthesia safety.

Insurance Companies : Mr. Mark Wood of the St. Paul Fire and Marine Insurance Company noted that in whatever organizational form, insurance organizations must at least break even or, better, make a profit to exist. Insurers have three ways to deal with problem losses: 1) increase premiums, 2) increase claims staff efforts to cut expenses on both sides of a case and, 3) work to prevent claims. It is in this List area that recent efforts have come. Companies have tried to identify the causes of loss and then inform their insured so that action can be taken to prevent repeat episodes. He cited the example of the rapid boom in hospital construction in the early 1970s leading to many crossed gas pipelines and resultant oxygen supply problem causing hypoxic accidents; insurers responded by pushing anesthesiologists very hard to have oxygen concentration monitors at all times. In the 1980s, the issue was sudden cardiac arrest which turned out, on later investigations, to be due to unrecognized hypoxia. This led to a strong push (including restrictive covenants and incentive discounts) for anesthesiologists to use pulse oximeter and capnography at all times to help insure appropriate oxygenation and ventilation.

Mr. Wood stated that there are fewer and less severe anesthesia-related insurance claims of all types, not only hypoxic catastrophes, since the time of the inception of the patient safety "movement" in anesthesia so that it is difficult to sort out what contributions various factors have made.

The Lawyers: Richard E Gibbs, M.D., J.D. from the Brigham and Women's Hospital in Boston discussed what impact the legal profession has had in " area. LESO cases tend to help define the standard of care with plaintiffs' experts trying to push it higher and higher and defense experts attempting to be realistic. Both are important because out of such discussions evolve expected behavior, which has included a high expectation for safe anesthesia care. Anesthetists are generally better today. Likewise, attorneys are much more sophisticated in prosecuting their cases. Dr. Gibbs stated that lawyers forced the malpractice issue and thus "tossed the hall to the anesthesiology profession, which caught it and ran with it."

Anesthetic Agents: Mr. George Griffiths of the Jansen Research Foundation suggested that improved anesthetic agents do have a role in the decrease in mortality and morbidity. He cited the development of current and future inhalation agents, beta blockers and opioids that allow smoother anesthesia with less stress to the patient. As he was the last speaker, he summed up by noting that, almost by definition, it is everybody involved all together who is responsible for the improvement in anesthesia care.

Discussion

Several points in the discussion period centered around the question of whether the improvements in care were simply a result of the natural evolution of practice and would have occurred anyway or whether the specific patient safety movement had made a special impact that would not have been otherwise seen. Opinions on both sides were voiced. Mr. Wood made a strong statement in favor of the safety efforts having definite benefits by noting that the profession of anesthesiology is the best example of an organized group effectively doing something constructive in the areas of risk management and quality assurance. Some members of the audience reminded the group not to underrate the importance of the individual clinician, the one who takes the blame when things go wrong and who should get the credit when things do better.

Dr. Eichhorn, Harvard Medical School and Beth Israel Hospital, Boston, is the Editor of the APSF Newsletter.

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Insurance Premiums Cut in New Jersey

by Ervin Moss, M.D.

On January 1, 1990, the Medical Inter-Insurance Exchange of New Jersey decreased malpractice insurance premiums for anesthesiologists by 14%. Them was a lesser across-the-board decrease in premiums for all physicians insured by M.I.I.E. of 5%.

The premium for anesthesiologists for a one million-three million occurrence policy is $16,300 and $18,870 for a two million-four million policy. In addition, a dividend check for $1,286 was sent to anesthesiologists insured by M.I.I.E. during the year 1978. This dividend was issued because of favorable claim experience on the professional liability policies that were written for policy year 1978. A total dividend of $3,115,233 was distributed.

The other major insurer of anesthesiologists in New Jersey Princeton Insurance Company reduced its premiums effective February 1. An 18% reduction was seen for the basic one million-three million policy with a 30% reduction in premium for greater amounts of coverage.

A fee ("loan certificate"') of $ 12,500 is required to obtain new insurance from M.I.I.E This certificate is fully refundable at the time of retirement, death, or upon leaving New Jersey. Also, those who initially invested $7,500 in 1977 are scheduled for return of their $7,500 investment upon approval of the State Insurance Commissioner. The M.I.I.E., incidentally, is represented on the Board of Directors of the Anesthesia Patient Safety Foundation by Mr. Peter Sweetland, President. The extra 9% decrease in M. I.I. E. premiums for anesthesiologists is attributed to decreased claims and the efforts of the New Jersey State Society of anesthesiologists in risk management.

Because the New Jersey standards have been officially in place since August 21, 1989 the M.I.I.E., as in Massachusetts, has already recognized and is anticipating a further decrease in anesthesia malpractice claims because of adherence to the all encompassing New Jersey standards of practice. A representative of the Princeton Insurance Co. stated, "Without a doubt, superior claim experience has caused this huge reduction in cost."

It is hoped that next year, with further favorable experience, anesthesiologists in New Jersey will see an additional decrease in malpractice insurance premiums.

Dr. Moss of Verona, NJ is an APSF Director and has been a driving force in anesthesia practice reform in New Jersey.
 

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New Jersey Continues as Center of Anesthesia Regulatory Activity

by Ervin Moss, M.D.

Preliminary Follow-up on NJ Standards

The comprehensive and detailed New Jersey anesthesia practice standards have had a significant impact on anesthesia care since their adoption early in 1989. The grace period for M implementation of the regulations expired in August of last year. Significant questions had been raised in the state concerning whether there would be compliance with the mandates, especially by the deadline.

Although all the data has not yet been collected, it is the opinion of the New Jersey Department of Health, as well as Ohmeda and the North American Drager Corporation that adherence to standards regarding replacement of anesthesia machines not complying with the regulations exceeds 90%.

Drager has replaced 50 anesthesia machines in New Jersey and has been able to update 97% of the machines for which retrofitting to current standards was requested. Ohmeda reported replacement of I 8 I "obsolete" (not meeting the regulation,) machines in New Jersey as a consequence of the standards. Sales figures fix)m any other manufacturers are not available at this time. In the majority of institutions, only one to four machines were replaced, but in several hospitals as many as 11 machines were purchased, replacing the entire anesthesia department's equipment.

Remembering that the New Jersey State Department of Health has now found compliance to be at the 90% level, the following summation of a survey taken through April 1989 indicates the weak points as of ton months ago.

Summary of Survey Completed April 1989 (717 Machines)

[The terms, "Current" and "Non-current" were used to describe those machines meeting or not meeting New Jersey standards.]

1 . 80% of hospitals responded to the survey.

2. 77% of the 717 machines failed to meet standards when the machines and the monitors were examined as a package

3 . 90% of noncurrent machines were in use with 10% in storage.

4 . 80% of current machines were used in the operating room while 50% of the noncurrent machines were also used in the operating rooms. The largest number of noncurrent anesthesia machines were found in labor and delivery rooms and cysto rooms.

5 . 92.3% of the 717 machines had an EKG monitor, the remainder without.

6. 90.2% of the 717 machines had an oxy8en monitor while 9.8% were without.

7. 5 1 % of the machines had a spirometer of some sort.

8 . 65. 1 % lacked a breathing system pressure monitor.

9 . Hospitals under 200 beds and over 500 beds had the greatest percent of current equipment with the larger number of noncurrent equipment found to be in hospitals from 200 to 500 beds.

10. 46.4% of the 717 machines were without endtidal PCO2 monitors'

11. 81.6% of 717 machines were equipped with pulse oximeters.

12. The oldest machine in use in New Jersey was manufacturered in 1950. One hospital had seven machines, some of which were manufactured in 1950, 1951 and 1952.

Twenty percent of the 100 institutions surveyed failed to respond to a questionnaire named by one anesthesia machine manufacture. The questionnaire was intended as a generic service, but some of the non-reponders had other brands of machines. In any case, the list of hospitals not responding was supplied to the State Department of Health by the New Jersey State Society of Anesthesiologists for priority inspections.

The State Department of Health Inspection Team has noted the replacement equipment in place, but there has been frequent failure to update conomitantly the associated policy and procedure manuals defining the standards.

In Massachusetts, downtime is permitted for disabled monitors to be repaired. In New Jersey, by contrast, the policy is to require back-up oximeters, oxygen sensors, and end-tidal C02 monitors to be available. Further, no anesthetic is to be administered, unless in life-threatening circumstances, when these monitors are not functioning. Such a policy statement is required in the department's policy and procedure manual.

The most frequent questions asked by hospitals pertain to the endoscopy suites and the use of so-called "conscious sedation" where oximetry, blood pressure monitors and EKG monitoring are required, but anesthesia personnel are not. This exception for personnel was based on organized and active protests against the involvement of anesthesiologists in these areas.

Using the publicity surrounding deaths and complication arising from conscious sedation, the N.I.S.S.A. presented arguments for the need for anesthesia personnel during endoscopy when IV sedation is given. This was not supported by both major malpractice insurers in New Jersey based on lack of claims experience. However several hospitals have moved their endoscopy activities to the operating room suites with anesthesia staffing available.

Although only two chiefs of anesthesia departments protested the requirement for board certification, both were grandfathered by having passed the College examination before 1972. One board certified anesthesiologist has come forth to file a suit against a hospital who refused to replace the nonboard certified chief. As the only board certified anesthesiologist in that hospital, he is attempting to force the hospital to comply with the standard. Another major institution has a search committee actively looking for a board certified anesthesiologist to replace the present non-board certified chief.

More information will be relayed as it is forthcoming. The New Jersey experience is unique and is providing precedent - setting data that being observed widely in other states across the country.

Post Anesthesia Care Unit Standards Approved

On January 10, 1990, the New Jersey Department of Health announced the successful completion of the Licensure Reform Project, including standards for Post Anesthesia Care Units.

This project of establishing hospital standards for some 32 hospital areas included the anesthesia practice standards. These were given top priority and passed into regulation as of January 1, 1989. The remaining standards have been approved by the Health Care Administration Board of the New Jersey Department of Health. The standards will become operational on July 1, 1990. For the next five months, training sessions are planned so that both surveyors and the hospitals will be ready by the implementation date

The New Jersey State Society of Anesthesiologists Committee on P.A.C.U. standards, consisting of Drs. Gerald Shapiro, Sanford Klein and Ervin Moss, was represented at all meetings concerning the P.A.C.U. standards, as were representatives of P.A.C.U. and Critical Care nursing organizations. The standards were published in the New Jersey regulations for a thirty day period and al comments were answered by the state. The only change as a result of these comments was a suggestion by the N.I.S.S.A. that discharge criteria be clarified.

The P.A.C.U. standards required 1) EKG monitoring, 2) the use of pulse oximetry on each patient "unless such monitoring is not clinically feasible for the patient," and 3) immediate access to end-tidal carbon dioxide monitoring.

The standards require that there be a physician director with overall responsibility for the post-anesthesia care unit and that the physician director may also be the director of the anesthesia services. It defines the credentials of the registered nurse staffing the P.A.C.U. and their training environments including Basic Life Support and Critical Care training.

The ratio of staff to patients was established to be at least two health care personnel, one of whom is a registered nurse and the other of whom is a licensed practical nurse or a physician, present whenever a patient is in the post-anesthesia care unit. Therefore if there is one patient in the P.A.C.U., a P.A.C.U. nurse and a support person would be present at all times. When there is more than one patient, there will be a ratio of at least one registered trained professional P.A.C.U. nurse for every three patients in the P.A.C.U.

The regulation mandates that a patient be accompanied to the P.A.C.U. by two individuals, one of whom, stationed at the patient's head, shall be a member of the anesthesia team. It requires an oral report on the patient's condition by a member of the anesthesia team upon admission to the P.A.C.U. It requires that a oral report of the anesthesia team shall stay with the patient in the P.A.C.U. at least until the patient's vital signs, including blood pressure, pulse and respirations, are recorded.

The regulation defines the necessary documentation of the patient's condition while in the unit by the nursing staff . Discharge shall be by discharge criteria, including the authority to discharge, which have been developed through the required written policies and procedures. Admission and discharge criteria are required in written policies and procedures that are reviewed annually, revised as needed, and implemented. Since the I.C.A.H.O. permits discharge by criteria, this wording would permit a department to write a protocol, for example, for discharge requiring a patient to be discharged only personally by an anesthesiologist.

Finally, the regulation requires that a P.A.C.U. shall be adjacent to or within the O.R. suite and likewise, the OB suite and that it be a restricted zone maintained as a dosed unit. Access to the restricted zone of the P.A.C.U. shall be through or past a control center It defines proper attire for P.A.C.U. staffs and others permitted access to the unit. It lists minimum equipment, educational program requirements, and Q.A. requirements.

For a copy of the complete regulation please write the New Jersey State Society of Anesthesiologists, Inc., 2 Princess Road, Lawrenceville, New Jersey 08648.

Dr. Moss, an APSF director, has been extremely active in the N.J.S.S.A. Standards Committee for some time.
 

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Features of Modern Anesthesia Machines

by Charles Whitcher, M.D.

Problems with oxygenation account for a great number of the serious mishaps and complications seen in anesthesia practice. (1) Many more mishaps of all types are attributed to human errors than to equipment failures.(2) The avoidance of human errors leading to hypoxemia may be accomplished by two main approaches: 1) education and 2) the use of equipment that is designed to reduce the possibility of the development of hypoxia. Discussed here are selected means by which well-designed equipment and, in certain cases, modernized equipment, may help avoid hypoxia thereby contributing to safe anesthesia practice

Machine Replacement vs. Upgrading with Modern Safety Features

Most medical care facilities and anesthesia practitioners are not in a financial position to replace anesthesia machines frequently or all at once. As a result, many machines still now in regular use are not of current design and were not originally equipped with a full array of the most modem safety features. For purposes of discussion, such machines are identified as "vintage" machines. With a single exception, important safety features can be retrofitted to vintage machines. Some of the issues to consider in retrofitting are cost-effectiveness, reasonable service fife and the availability of funds for machine replacement vs. upgrading of existing machines.

Specific Safety Features Which May be Missing on Vintage Machines

Table I fists selected features of "modem" anesthesia machines. Any of these features may be missing from machines manufactured in the U.S. before 1984. Except for the oxygen/nitrous oxide ratio protector/controller, all listed freatures may be retrofitted to vintage machines. 'The purpose of each of these features is the prevention of hypoxia.

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Table 1. Safety Features of Modem Anesthesia Machines

1 Oxygen concentration monitor

2. Low oxygen pressure N20 cutoff ("fail safe7')

3. Oxygen supply pressure failure alarm

4. Single oxygen flow control knob

5. Touch coded oxygen How control knob

6. Oxygen flow meter at extreme right (U.S.)

7. Central gas supply pressure gauges

8. Color coded flow meters & control knobs

9. Oxygen/nitrous oxide ratio monitor/controller

10. Locking common gas outlet

11. Pin index safety system(indexed cylinder yokes)

12. Diameter index saw system (indexed pipeline

inlet connectors)

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1. Oxygen Concentration Monitor (With Low Concentration AL-mm)

The oxygen concentration monitor in the breathing system "oxygen analyzer" is the ubiquitous, standard-of-care monitor designed to measure oxygen concentration. In the circle breathing circuit, the most useful measurement site is within the breathing circuit, near the inhala6on check valve. In the modified Mapleson D (Bain) type system, the usual measurement site is within the fresh gas line.

Causes of inappropriate oxygen concentrations include: unrecognized nitrous oxide How (the bobbin of the N20 flow meter in pinned inconspicuously above full scale), a flow meter control knob is mistaken (e.g. air used instead of oxygen), the oxygen supply pressure fails, a disconnection from the oxygen source occurs, or the gas from the oxygen source is not pure oxygen.

Maintenance and Calibration

As with ad monitors, the "oxygen analyzer" has limitations. Most units are of the galvanic or polarographic type. To remain operable, consumable components of the sensors of these monitors must be regularly replaced (galvanic cell cartridge or membrane and electrolyte). Calibration is recommended at least daily. Three precautions about calibration procedures merit attention:

1 .Allow for the normally long equilibration time of one-half to three minutes. Calibration is useful only when sufficient time is allowed for complete equilibration.

2 .Test for failure of span, an important early failure mode. A fading monitor may calibrate only to 2 1 % oxygen or only to 100%. Inaccurate readings may be seen at concentrations other than those at the single calibrated value. Proper calibration requires two points, usually room air and 100% oxygen.

3. Assure that I 00% oxygen is actually present at the sensor during the span test. At the usual installation adjacent to the inhalation check valve of the circle absorber, oxygen may bypass the sensor site. Thie problem is usually preventable by the use of high flow rates of oxygen, e.g. ten liters per minute.

Even with appropriate calibration, data from the oxygen analyzer must be interpreted with caution. A reading of I 00'Y. oxygen does not guarantee that the patient is receiving 100% oxygen. In case of a disconnection between the Y-piece and the absorber, with the oxygen analyzer reading I 00'Yo, the patient may breath room air during spontaneous ventilation or not at all if dependent on controlled ventilation.

In order to minimize the inconvenience of calibration, the practitioner can begin the machine check out by detaching the oxygen concentration sensor and allowing stabilization in room air as other preparations for anesthesia are conducted. After about three minutes (varies among brands see your manual), the monitor should read 20-22% oxygen. failing this, the monitor must be adjusted to 2 1 % oxygen. Then the sensor is reattached to the breathing system with a high How rate of oxygen. After about three minutes, the monitor should read 97-103% oxygen. If not, span adjustment is attempted to bring the reading to 100% oxygen. If any adjustment is made at this stage, the room air test must be repeated. If the monitor then reads 20-22% without further adjustment, calibration is appropriate. Failing this, the analyzer should be replaced while being examined, tested and, if needed, serviced or even repaired.

Alarms and Adjustments

On the one hand, anesthesia care involves multiple simultaneous responsibilities and several competitors for attention. Since the anethesiologist physically cannot focus full attention on all of the component elements at once, there is the possibility of distraction. On the other hand, a well designed alarm has a single specific purpose and cannot be distracted. This is to the patient's advantage.

Alarms should be designed so that they can be kept on throughout an anesthetic, without imposing Use al-mm or causing other inappropriate distractions. It is good practice to keep alarms thresholds set at levels sufficient to sustain a reasonable margin of safety appropriate for the specific clinical situation. If a minimum of 30% oxygen is desired, the alarm might be set for 29% oxygen. Between cases, the monitor should remain on and distracting alarms can be prevented by maintaining a sufficient oxygen flow rate. The minimum flow rate of a modern anesthesia machine is usually sufficient.

Oxygen analyzers of the modem paramagnetic, Raman, and mass spectrographic types may require less frequent calibration and service than the usual galvanic and polarographic types. These newer analyzers are capable of rapid measurements. By sampling continuously at the Y-piece or endotracheal tube, both inhaled and end-tidal oxygen concentrations may be measured. Adequate inspired to endtidal oxygen concentration difference (e.g. three percent to five percent oxygen) suggest that the patient has actually received a safe concentration of oxygen, distributed oxygen to the tissues, employed oxygen in metabolism and exhaled the excess oxygen.

2. Low Oxygen Pressure Shut Off ("Fail Safe system")

The low oxygen pressure shut off device promptly terminates the flow of nitrous oxide if the oxygen supply pressure fads. further delivery of nitrous oxide and volatile agent is prevented. With gas supplies cut off, the rebreathing bag or bellows empties quickly. This draws attention to the problem. Causes include: empty oxygen link; interrupted oxygen flow from the high pressure oxygen source; and a compressed, kinked, or disconnected high pressure oxygen hose to the machine.

It is important to recognize that the low oxygen pressure shut off feature does not cut off the flow of gases other than nitrous oxide. Thus, anesthesia machines equipped with helium may deliver 100% helium a hazard often overlooked. Protection against " potential cause of a major hypoxic event is provided both by constant vigilance and the continuous monitoring of oxygen in the breathing system with a concentration monitor with an audible alarm as discussed above.

Test Procedure

When a central oxygen supply system is used, shut off the oxygen cylinder(s) on the anesthesia machine and connect the high pressure oxygen supply hose to its source After providing for the scavenging of nitrous oxide (see Caveat 1. below), establish flow rates of nitrous oxide and oxygen and then disconnect the high pressure oxygen hose at the wall or ceiling connector. After a few moments, both oxygen and nitrous oxide flow rates should fall to zero. If oxygen is supplied only from cylinders, establish flow rates of nitrous oxide and oxygen as above, then turn off the oxygen cylinder. Again, after a few moments, the flows should fag to zero.

Caveat 1. Without due care this test causes occupational exposure to nitrous oxide. Minimal exposure by venting the common gas line to suction. Disconnect the common ("fresh") gas fine connector at the machine end. When nitrous oxide is flowing during the test, place the suction line up to or near the common gas outlet. After the test, reattach the common gas connector.

3. Oxygen Supply Pressure Failure Alarm

The oxygen supply pressure failure alarm sounds an audible alarm in case of oxygen supply pressure loss. Usually this feature is combined with the low oxygen pressure cutoff feature, so that the alarm sounds and the flow of gases stop at about the same tune. With the alarm calling attention to low oxygen pressure, the shut off of all gases is likely to be noticed.

Test Procedures

Conduct this test along with the abuse shut off test. Hear alarm signal as the flow of nitrous oxide oxygen falls to zero.

4. Single Oxygen flow Control Knob

A single flow control knob for oxygen reduces the possibility of selecting a wrong knob for adjusting the oxygen How rate. Certain vintage machines have separate knobs for administering high raw and low oxygen flow meters. This is inherently dangerous and should be considered for replacement. failing this, extra attention to the oxygen concentration monitor is mandatory.

5 . Touch-coded Oxygen flow Control Knob

The modem oxygen flow control knob is distinguished from all other flow control knobs by its larger diameter, and fluted design. These features reduce the possibility of delivering an inappropriate gas mixture by facilitating instant tactile recognition of the oxygen flow control knob, Regardless of color blindness and poor ambient fighting conditions.

Inspect your anesthesia machine for the presence of a modem fluted, large diameter oxygen flow control knob. If not present, it should be installed.

6. Oxygen flow Meters on the Right (U.S.)

The U.S. standard location for oxygen flowmeters is at the extreme right side of the How meter control panel. This standardized location helps prevent the adjustment of the wrong flow meter. This feature reinforces the effectiveness of points four and five above

Inspect the front panel of your anesthesia machine to check that the oxygen flow meter is positioned to the extreme right.

7. Pipeline Pressure Gauges

Pipeline pressure gauges measure gas pressure in the high pressure lines of oxygen, nitrous oxide and air. Each pipeline pressure gauge is normally located adjacent to the corresponding cylinder pressure gauge, within easy view of the practitioner. Gauges verify that hoses are connected and pressurized and assist in localizing any failure of the gas supply.

Inspect the pressure gauges, viewed from the front of anesthesia machine to two gauges for each gas. Pipeline gauges are distinguished from cylinder gauges by the label and pressure range. Pipeline gauges have typical range of 0-100 psig; cylinder gauges have much higher maxima.

8. Color Coded Flow Meters and Flow Control Knobs

Flow meter tubes, or the background material behind each, and flow meter control knobs, are uniquely colored for each gas represented: in the U.S., green for oxygen, blue for nitrous oxide and yellow for air. Color coding is intended to reduce the possibility of mishap due to selection of a wrong flow tube or control knob. Many other countries use different color coding: beware both when working outside the U.S. and when using imported anesthesia machines that have not been retrofitted.

9. Oxygen-Nitrous Oxide Ratio Monitor and/or Controller

The oxygen-nitrous oxide ratio monitor senses the ratio of flow meter settings for nitrous oxide and oxygen and issues an alarm when the ratio is unsafe. A ratio controller assures that flows cannot be adjusted outside a specific range of ratios. Specifically, pure nitrous oxide cannot be administered.

Test Procedure

Set a usual flow rate of oxygen (e-g. 2 liters/min), then increase the nitrous oxide How from zero up to a rate above the acceptable ratio. Results vary with the make of anesthesia machine. In the NA Drager version, once the specified maximum ratio has been reached, no further increase of nitrous oxide How rate is possible. In the Ohmeda version, once the specified maximum ratio has been achieved, a further increase of the nitrous oxide flow rate automatically increases the flow rate of oxygen (thus preventing & minimum proportion of oxygen at any total flow rate).

Others

Other pertinent safety features aiding in the prevention of hypoxic gas mixtures, considered in a previous article by Beverly Nichols, C.R.N.A. in this publication, are listed here for completeness:

10. Pin index safety system (indeed cylinder yokes-).

11. Locking common gas outlet.

12. Diameters index safety system (indexed pipeline inlet connectors).

Safe Practices and the Prevention of Hypoxia

All of the test and calibration procedures mentioned should be considered saw practices to aid in hypoxia prevention. An additional saw issue not for the machine itself, but applicable to all anesthesia machines, both vintage and modem, is suspension of all gas and scavenging hoses off the floor.

Hoses on the floor may be occluded by the wheels of any heavy piece of equipment such as an anesthesia machine In the case of an oxygen hose,

the oxygen supply may W. Collapse resistant oxygen hoses are available and offer some protection. In case of a scavenging hose, occlusion may cause back pressure, preventing exhalation in a breathing system. Intravenous poles may assist in the safe suspension of all hoses. As a supplement to the practice of keeping scavenging km off the floor, relief vanes and collapse proof hose offer protection.

Conclusions

Anesthesia-related mishaps will continue to occur because anesthesia is administered by humans. At least half of major mishaps may be considered preventable. Vigilance is a critical factor, but, realistically, one which is subject to only limited improvement because human factors are traditionally difficult to control. On the other hand, safety features and monitoring devices have only a single function to perform. Given well designed alarms, monitors can help compensate for fatigue, lapses of vigilance, and distractions. Although anesthesia machines themselves only rarely appear to play a primary role in substantive mishaps, it is intuitively logical that machines with appropriate safety features can help reduce both the number and severity of mishaps. Anesthesia equipment is a relatively controllable modality compared for human vigilance.

Due attention should be paid to safe practices such as the thorough regular machine checkout procedure the use of appropriate monitors and their calibrations keeping alarm on and keeping hoses suspended when possible. Likewise, careful attention must be given to the relative merits of the upgrading of vintage anesthesia machines with safety features that can be retrofitted versus the timely replacement of those vintage machines.

Dr. Witcher, Stanford University Department of Anesthesia, is a member of the APSF Education Committee.

References

1. Cheney FW Potential Risks and Causes of Incidents. In: Gravenstein JS and Holzer JF (eds) Safety and Cost Containment in Anesthesia. Boston: Bufferworth's 1988, 11-20.

2. Cooper JR Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection . Anesthesiology 1984; 60:34-42.

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STA Announces first Annual Meeting: January in Florida

by N. Ty Smith, M.D.

The Society for Technology in Anesthesia (STA) is planning its first Annual Meeting for January 18-20, 199 1, in Disney World, Florida. A major focus of STA is the education of health care workers who are using technology with enthusiasm or without enthusiasm. The lack of anesthesiologists' education in the use of technology was emphasized at the first business meeting of STA, held at the ASA Meeting List October "STA 91 " was inspired by that finding and, accordingly, will focus on education. As is singularly appropriate, one of the foremost anesthesia educators in the world, Dr. J.S. Gravenstein, will run the meeting.

In addition to the scientific sessions, there will be two tutorial sessions. The first will be entitled "The Uncertainty of Measurements and Monitors." The major questions asked will be "How accurate can we hope to be?" and "How accurate do we need to be?" The all-star cast of speakers includes Drs. Allen Ream, John Severinghaus, David Swedlow and Terry Vitez, speaking on blood pressure, oximetry, gases, and electrolytes. The second tutorial will address the question, "How Can Technology Help Me Give Anesthesia via a Closed Circuit?" Drs. Jerry Caulkins, Alan Grogono and Dwayne Westenskow will organize this section of the meeting.

Rounding out the theme of education will be a distinguished lecture by Dr. Richard Kitz, on the subject "Technology and Medical Education: What Should the Relationship Be?" Dr. Kitz will explore what happens to physicians who have received intensive training in technology during medical school. Ultimately, we hope to find out how an organization like STA can help with this educational process.

Just before the STA 91 Meeting, at a nearby site to be determined, Ohio State University wig sponsor a Review Course on Monitoring. The faculty for the Course will be from Columbus. Information concerning this Meeting can be obtained from Ms. Arlene Rogers, 410 W. 10th Avenue, Room N-429, Columbus, Ohio 43210.

Those interested in the STA 91 Meeting should contact Ms. Geni Kuzava, P.O. Box 382, Hastings, MI 49058. Those interested in submitting an abstract should contact Dr. Kevin Tremper at the Department of Anesthesiology, University of California, Irvine, 101 City South Drive, P.O. Box 14091, Orange, CA 92613. The deadline for abstracts is August 1, 1990. Both poster and oral presentations will be accepted. Poster presentations can be a demonstration of a gadget, a computer program, or a method, for example. Use your imagination. Abstracts from the Meeting will be published in the Journal of Clinical Monitoring and will therefore be citable for four years.

Another meeting sponsored by STA is the 6th International Symposium on Computing in Anesthesia and Intensive Care, to be held in Hamamatsu, Japan, April 15-20, 1991. Please contact either Dr Kazuyuki Ikeda, Chairman, Department of Anesthesiology, Hamamatsu University, School of Medicine, Hamamatsu 431-3 1, Japan, or Dr. Yasuhiro Fukui at Deparment of Applied Engineering Tokyo Denki Univ., Habyama Saitam 3050-3, Japan, for further information about the meeting

If you attend the ASA Meeting in L-is Vegas, October 19-23, 1990 be sure to plan to attend STA's second Breakfast Panel. This year's topic will be "How Can Technology Help Me With Quality Assurance?" Anything that can make life easier and fairer in " difficult area will be welcome, and the group of outstanding panelists promises to do * that. -Be panel wig be moderated by Dr. John Eichhorn, and will include Drs. Jerry Cohen and Terry Vitez.

Plan now to attend these interesting and valuable Meetings.

Dr. Smith, University of California, San Diego, is President of STA.
 

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From the Literature: Handling an Anesthetic Related Death

Bacon, A.K., Death on the Table. Anesthesia 1989:44;245-248.

Dr. Bacon provides a prescription for responding to a death in the operating room and discusses the human relationships that are touched by this rare and tragic event.

He begins with a few "golden rules" for both the family and the care-givers: how to (1) break the news, (2) give the facts, (3) allow ventilation of emotions and grief, (4) answer questions, (5) restate the facts, (6) outline the steps that have to be taken by law, (7) express continuing support for the family and sympathy with them in their time of tragedy.

Following this initial and brief meeting, he suggests the medical team (surgeon, anesthesiologist, nurse, and another professional such as a chaplain or social worker) break for a final briefing for twenty minutes, and then return to the family to discuss the formalities of what happens next.

Dr. Bacon implies familiarity of the team with hospital procedures such as completion of the medical record, notification of the family doctor and the filing of incident reports and other forms. He specifically notes checking and recording the anesthesia machine and medication ampules utilized.

Further attention is directed to the possibility of civil proceeding, including the preparation of a narrative of the events as soon as possible "written to assist in defense of possible legal proceedings," and a review with a senior anesthesiologist on staff. Finally, he expresses concern about debriefing the operating team, particularly in extremely stressful circumstances such as unusual media coverage, patients who were members of the surgical team and children.

Three questions come to mind. Is this really necessary? The answer on both moral and pragmatic grounds is yes. Our final service to our patients is the duty owed to the family. Moreover, there are suggestions that malpractice actions are driven by bad feelings as well as bad outcomes; such bad feelings have consisted of guilt, rage, grief, surprise, betrayal and abandonment. In the majority of our national and international efforts at quality assurance and risk management, we have begun to address adverse outcomes, but have barely scratched the surface of the bad feelings that may be associated with these bad outcomes.

Is it dangerous to our personal liability exposure to involve ourselves with families in such a manner following a catastrophic event? There are suggestions that just the opposite may be true. "Physicians, like anyone else, will make mistakes".(1) Many legal actions against physicians are driven not by the quality of the care but by the anger, frustration and outrage of family members who perceive they have not been communicated with fully and in a timely manner. Communication after a catastrophe is no antidote to lack of preoperative evaluation, preparation and communication prior to the catastrophe, as well as selection and administration of an appropriate anesthetic and documentation of care.

Nevertheless, there are suggestions that the "sharing of uncertainty" reinforces the principles and practices of informed consent.' It is important to remember that in communicating with the family following a catastrophe, an expression of sorrow or regret for the situation without admitting guilt or negligence is inadmissible as evidence of liability in several states, Massachusetts being one of them. This includes any statements, writings or benevolent gestures relating to the suffering of the victim of an accident. Such expressions (with the security of protection under the law) underscore the clinician's empathic and mature response to a tragic situation.

Is there comparability between the Australian legal system and the American ? It is not completely dear. Yet, although the laws may be different, it is hard to believe that the feelings of those who are touched by medical tragedy are.

Very few practitioners of anesthesia have dared to approach this sensitive subject. Dr. Bacon presents a cogent overview of concerns material to the family, the anesthesiologist, the operating room team and -the practice of medicine.

Abstracted by Robert S. Holzman, M.D., Harvard Medical School and Children's Hospital, Boston.

References

1. Hilfiker D. Facing our mistakes. N Eng J Med 1984: to; I IS122.

2. Gutheil TG, Bursztajn H, Brodsky A. Malpractice prevention through the sharing of uncertainty: Informed Consent and the Therapeutic Alliance N Engl J Med 1984:3 1 1'49-5 1.

3. Mass. Gen. Laws c. 233, sec. 23D (1986).
 

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International Committee for Prevention of Anesthesia Mortality and Morbidity to Meet in Warsaw in Fall

ICPAMM has met three times to discuss methods employed by various countries to study anesthesia mortality and morbidity.',',' The next meeting will be convened in September, just before the start of the European Congress of Anesthesiology in Warsaw, Poland.

The objective of the meeting is to share information on the latest results of ongoing or recently completed studies of anesthesia outcomes. Given the recent events in Eastern Europe, this should be an excellent opportunity to share what has been learned about methods and results so that studies can be designed and implemented in countries that previously did not have the freedom to share outcome statistics.

The agenda includes reports on outcome studies in Australia (the Australian Incident Monitoring System), the UK. (the Confidential Enquiry on Post operative Deaths), Canada (the Manitoba Study), the U.S. (Pilot Study of Anesthesia Adverse Outcomes and various Quality Assurance studies). The Danish-American randomized trial of pulse oximeter will (hopefully) be recently completed and at least a preliminary report of findings will be presented. Discussion groups are planned to address the following questions. What method of study of outcomes is most revealing about causes and potential remedial strategies?; What has been the usefulness of anesthesia M&M studies?; What strategies for reducing risk are most effective for developing countries?; What direction should anesthesia patient saw take in the 1990's?

Participation is by invitation only. If you have something to share with this group, please contact Jeffrey Cooper, Ph.D., Department of Anesthesia, Massachusetts General Hospital, Boston, MA 02114 for more information.

References

1. Keats AS, Siker ES. International Symposium on Preventable Anesthetic Mortality and Morbidity Report of Scientific Meeting Anesthesiology 63:349-50, 1985.

2. Cooper IB: Conference Report 1986 Meeting of the International Committee for Prevention of Anesthesia Mortality and Morbidity. Can J Anesth 35:287-93, 1988.

3. Cooper IB: Report of a meeting of the International Committee for Prevention of Anesthesia Mortality and Morbidity. Anaesthe5@7 44.441-443, 1989.

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Letters to the Editor:

Result of Standards Cited as Unclear So Far

To the Editor:

Dr. Moss's description of the battle to introduce standards of practice in New Jersey (June, 1989) is fascinating. In his article' he repeats what others have said about the effect of the application of standards of care in Massachusetts: that is, since they went into effect on July 1, 1987 there have been no anesthesia-associated deaths. Unfortunately there is no evidence to support the implication of cause and effect.

There is some indirect evidence of a sharp fall in mortality between 1955 and the end of 1983. Our insurers (the Joint Underwriting Association of Massachusetts or JUA) tell us they have received no claim arising from incidents after July, 1987 in which the standards were applied and the monitors were used. But the period between January 1984 and June 1987 has not yet been studied and no valid before-and-after comparison can be made.

The malpractice premium discount offered to JUA-insured Massachusetts anesthesiologists resulted from two separate occurrences. The first was the leadership displayed by Massachusetts anesthesiologists in developing and applying risk management techniques. 5,6 The second was the early finding of the ASA Closed Claim Study which showed in retrospect that 29% of anesthetic deaths might have been prevented if certain standards of care and monitoring had been in use.

The JUA believes that adoption and enforcement of practice standards for all specialties will reduce the frequency of claims, and they are using the discount for anesthesiologists as a carrot to dangle in front of some reluctant donkeys. The New Jersey insurers may be correct in taking a wait and see position on premium reduction.

Gerald L. Zeitlin, M.D. Lahey Clinic Burlington, MA

References

1. Moss E. New Jersey enacts anesthesia standards. APSF Newsletter 1989;4,2:13-18.

2. McGinn PR. Practice standards leading to premium reductions. American Medical News 1988;31,45: 1.

3. Brahams D. Anaesthesia and the law; Monitoring. Anaesthesia 1989;44:606-607.

4. Zeitlin GL. Possible decrease in mortality associated with anaesthesia. Anaesthesia 1989;44:432A33.

5. Eichhorn JH, Cooper IB, Cullen DJ, Maier WR, Philip IH, Seeman RG. Standards for patient monitoring anesthesia at Harvard Medical School. Journal of the American Medical Association 1986;256,8: 1017-1020.

6. Zeitlin GL, Cass WA, Gessner JS. Insurance incentives and the use of monitoring devices (Letter). Anesthesiology 1988;69:441.

Editor's note: Dr. Zeitlin's letter was received prior to the announcement of the malpractice insurance premium reductions in New Jersey and Texas

Aviation Analogies Revisited: Removal of Distractions Urged

To the Editor:

An article and a letter in the APSF newsletter draw attention to the many parallel safety rules, regulations, and practices which exist between the anesthesia profession and the aviation industry. The inference is that the anesthesia profession, by emulating the well-proved safety practices of the aviation industry, can seek to improve its safety record to the enviably high level currently enjoyed by commercial aviation.

There remains an aviation mw regulation, that of excluding extraneous people from the cockpit and then dosing and locking the cockpit door to prevent disconcerting distractions during the critical times of take-off and landing, which the medical profession, in general, and the anesthesia profession, in particular, have faded to copy. To the contrary, the doors to operating suites, labor and delivery suites, radiology departments, special procedure rooms and emergency departments have been flung open to anyone and everyone at any time and for any reason in order to accommodate the new age of patient enlightenment.

At the same time, efforts are being undertaken to obtain the cooperation of the manufacturers of medical monitoring devices to standardize alarm sounds to prevent the distracting cacophony frequently heard in the anesthesia workplace. Prudence and logic dictate that efforts exerted toward reducing distractions in anesthetizing locations should be applied to all discoverable and correctable distractions.

The pilot who closes and locks the cockpit door should be sending a message to the entire medical profession. Those people not essential to the task at hand and who may serve as distractions to those who are have no place in critical places at critical times. In this regard, the aviation industry is a quantum leap ahead of anesthesiology. We, the medical profession as a whole and the specialty of anesthesiology, in particular, must heed the pilot's warning and follow his example.

John G. Morrow, III, M.D. Macon, GA

Bus Driver Better Model

To the Editor:

The reappearing analogy between anesthesia and cormner6al aviation is far too presumptuous to support the current trend of upgrading or replacing equipment and anesthetic techniques in the name of safety. The 50 year old DC3 is still being used by numerous charter and scheduled airlines; safety is not one of the major reasons for the popularity of the DC IO, whose development is so far advanced from the earlier aircraft that there is no analogy to the development of anesthesia.

After all, most of our anesthetic machines still depend on turn of the century technology of glass rotameters, needle control valves and plenum vaporizers, albeit with some modifications. True, the relatively recent use of polypharmacy, electronic monitors, and expensive apparatus is breathtaking, but usually at the expense of the development of clinical skills and, with the possible exception of pulse oximetry, of no measured benefit.

The raison d'etre of commercial aviation is safe transportation, * as the raison d'etre of anesthesia is safe surgery. But even with today's impressive jumbo jets, one is still able to choose more basic, and probably less safe forms of transportation, such as walking, the bus, or a train.

My favorite analogy to the anesthesiologist is the endangered Pittsburgh jitney driver. The patient, rather than being the passenger, is the automobile. Usually in good repair, occasionally having seen better times, but by necessity, always intimately understood by its driver, who has developed a confident "feel" for his patient by utilizing his senses and perhaps the few basic safety monitors of engine oil pressure, temperature, and fuel reserves. At one time he had to compete for his passengers by providing an excellent service; but now his passengers are the regulatory agencies, insurance companies, risk management attorneys and other taxi drivers who would rather be jumbo-jet pilots. Today's passengers are assigned to him; often back seat drivers who forget that they used to give their operator sufficient discre6on and incentive to get them to their destination as efficiently as possible. In order to keep his passengers happy, today's driver is highly regulated and his numbers strictly controlled. He needs to paint his vehicle yellow and uses a taximeter to determine his fare. He needs air conditioning that strains the engine further, and a two-way radio that often relays confusing messages. Delays are commoner, costs are higher and the public unhappier.

A safe practice that stimulates innovation is encouraged by less, rather than more regulation. The enforcement of published standards of care as well as the assignment of exclusive hospital contracts fosters a mediocre anesthetic practice. There's little wrong with cultivating quality by allowing individual discretion and healthy competition, with patients and their advocates being the best judges of a good anesthetic.

To keep in perspective with ordinary living and to keep costs down by weeding out the superfluous from the useful, anesthesiologists should have to contribute to the cost of equipment and supplies. (Would you comply with published standards of care and routinely use a cardioscope for all healthy patients if the ECG electrodes cost three times as much as your lunch?) Of course, some anesthesiologists will find themselves with plenty of free time to upgrade their skills and knowledge, but that's probably why we're in this regulatory mess in the first place.

Hansel de Sousa, M.D. Pittsburgh, PA

Dangers of Syringe Contamination Cited

To the Editor:

If your anesthesiologist told you he was going to give you a cc. of fentanyl from a syringe that was used on nine other patients during the past five days, you would be horrified. Unbeknownst to patients, this happens every day.

A poster presentation at the 1989 S.A.M.B.A. Meeting, "Bacterial contamination of Anesthesia Syringes', looked at this issue with surprising candor. The study evaluated the bacterial contamination of syringes used to administer anesthetic medication. No bacterial contamination was found although 22 percent of these syringes were used on multiple patients and 13 percent were used on multiple days!

In the days before AIDS, many of us used the same syringes on multiple patients or the same succinylcholine drip on two or three patients. Even with the AIDS crisis, many anesthesia personnel find it too wasteful or too much bother to use new syringes on every patient. This poster is evidence that this is a problem at many institutions.

The ASA's Surgical Committee statement on reuse of syringes was made several years ago with very little publicity or fanfare. This APSF Newsletter is an excellent forum to reiterate the concept that such practice is unacceptable.

Henry L. Sherwood, M.D. Annapolis, MD

References

1. Ryckman, ST. Bacterial Contamination of Anesthesia Syringes, poster presentation; Society of Ambulatory Anesthesia, San Antonio, 1989.

Noise and Alarms: Dangerous Distractions

To the Editor:

Two underemphasized factors, I believe are increasingly contributing to human error during the administration of anesthesia. They deserve the attention of anyone studying anesthetic accidents and their prevention.

First, there has been a great increase in the amount of ambient noise in the modem operating room. Every newly introduced piece of equipment makes its own contribution.

Noise generators in a typical operation room include:

1. Air conditioning inflow

2. Warming cabinet (fan)

3. electrocautery (fan and tone)

4. C02 analyzer (fan)

5. Surgical suction sometimes two (constant hiss)

6. Gas-powered Ohio anesthesia ventilator (constant hiss, and intermittent cycling noise)

7. Tape-recorded music or radio, playing at desire of surgeon or anesthesiologist, or both (never at my desire!)

Additional sources in special areas are:

8. Operating microscope (fan)

9. Opthalmic cutter-evacuation (constant pump noise)

10. Laser (fan)

11. Vapor evacuator for orthopedic cement (fan)

12. Red-cell processor (suction and centrifuge)

13. Heart-lung machine (rotary pumps)

When many of these things are going, it is more like working in a factory than in an operating room. I believe that this high level of noise detracts from patient safety (a) by impairing communication among the members of the team, and (b) by distracting the anesthesiologists attention. I know of several near accidents when a ventilator was turned off, supposedly for a short time to facilitate some surgical maneuver, and the anesthesiologist faded to switch it on again. In older, quieter days one could not fail to notice the absence of the intermittent cycling sound but now, with so many fans humming and music playing, it is easy not to notice that the ventilator is silent.

An additional factor in my hospital is that, since the operating suite was remodeled a few years ago, the accous6cs have been changed greatly for the worse. I don't know exactly why I presume that it is dependent upon the sound-reflecting and sound distoring qualities of the wall, floor, and ceding surface but when a paper package is opened (and there are many) the noise created by the tearing or crushing of the paper drowns out any words being uttered in the room at that moment.

I believe the problem of noise should be brought to the attention of manufacture so that designers and engineers could pay more attention to it and seek solutions.

The second factor which urgently requires study is the confusion produced by the proliferation of alarms. There are so many buzzers, whistles, and beeps several resembling each other yet no logical system or arrangement exists.

Here is a list of alarms in a typical modern operating room:

1. Well-mounted gas pressure alarms for oxygen, nitrous oxide, compressed-air, surgical vacuum, gas evacuation, and nitrogen

2. Wall-mounted alarm for faulty electrical ground

3 . High or low heart-rate EKG monitor

4. High or low reading on intra-arterial pressure monitor

5 . High or low reading on non-invasive blood pressure monitor

6. High or low pulse rate, high or low saturation on pulse oximeter

7. High or low inspired oxygen on oxygen analyzer

8. High or low reading on end-tidal C02 analyzer

9. High or low temperature on electric thermometer

10. Ventilator disconnect alarm

11. Electrocautery "switched-on" signal 12. electrocautery faulty ground alarm

13. Electro-cautery signal indicating use of cauterizing current

14. Electro-cautery signal indicating use of "cutting" current

Each one of these has a buzzer, or a "beeper" or a gong or an oscillating sound. Some sound off so infrequently that is hard to remember where they are in the room and what they signify. Others go off so often that they are commonly turned off!

All of these machines are making great contributions to patient care so, of course, they are necessary. The point I wish to make is that it is time for manufacturers to get together, as they have done with other anesthetic equipment (e.g. endotracheal connections) to bring some order out of this chaos. Ideally, one alarm sound could serve for all with a verbal message on a screen or LED identifying the problem.

David V. Thomas, M.D. Los Altos, CA

Potassium, Epi Removed to Prevent Accidental Misuse

To the Editor:

Though we were aware of many unpublished deaths from the erroneous injo6on of concentrated potassium chloride, it was a similar tragic death in our own hospital when potassium chloride was injected instead of a diuretic that caused us to review our handling of potassium chloride and other concentrated solutions throughout our hospital.

We could not identify any circumstances on the ward or in the operating room where concentrated potassium chloride solution would be needed at a moment's notice. As we have a 24-hour pharmacy intravenous preparation service, we withdrew the vials of concentrated potassium chloride solution from the operating rooms, ICU, and other patient care areas to be held in the hospital's pharmacy. The pharmacy now pressure the diluted KC I solution ready for administration to the patient upon receipt of a prescription (order).

This arrangement prevents a repetition of these accidents, which we understand from the Medical Defence Union are a frequent cause of accidental hospital deaths in Britain.

We have also withdrawn epinephrine in the 1: 1000 concentration (1 mg in 1 ml) as this also is potentially lethal when injected without dilution. There have been many reports of accidents in which epinephrine was administered when ephedrine or Pitocin was intended. Epinephrine 1:10,000 solution is the concentration now stocked in our operating room.

We would urge hospital staffs to implement this policy wherever possible. In hospitals without a 24-hour pharmacy service, we would recommend that concentrated potassium chloride solution be kept under separate lock and key to prevent accidental confusion between KC I and NaCl vials in the hospital's drug cupboards (especially in the O.R. and anesthesia work area).

It is hoped that the distinctive black flip-off type caps with black metal closures for vials and the black hands on ampoules, evolved by ASTM Subcommittee D I 0. 3 4 for these potentially lethal concentrated solutions, will help users identify them when this new packaging is adopted late in 1989.

Floyd Brauer, M.D.

Leslie Rendell-Baker, M.D. School of Medicine

Loma Linda (CA) University

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ASA Publishes Safety Information Brochure for Public

by Adrienne C. Lang

The ASA Office of Governmental Affairs (OGA) has prepared a comprehensive brochure detailing the patient safety efforts by the specialty of anesthesiology. Entitled "FYI ... A commitment to Patient Safety," the twelve-page document is intended to be distributed to a wide audience, including state and federal government officials (such as insurance commissioners and legislators), liability insurance carriers, patient information groups and hospital administrators. The OGA has provided copies to each state anesthesiology society for their local distribution.

The printed brochure begins with a description of the specialty of anesthesiology presented in an easy-read, non-technical commentary. This is designed for non-physician readers and highlights the medical responsibilities of the anesthesiologist, the dangerous nature of anesthetic drugs, and the technological innovations which have propelled the specialty.

ASA's initiatives to improve the quality and safety of anesthesia cam are summarized, including the peer review activities, patient safety videotapes, the establishment of APSF and the Closed Claims Study. These activities by ASA and others, such as the Harvard Anesthesia Risk Management Committee are the foundation for successful grassroots activities.

The state component societies of ASA are vital to the dissemination of risk management and patient saw initiatives. Further, of course, it is at the state level where these initiatives have yielded positive results with regard to the adoption of standards and also reductions in malpractice premiums. Therefore, "A Commitment to Patient Safety" details the precedent-setting insurance activities in Massachusetts, with additional information from Arizona, Georgia, Oregon, New York, New Jersey and Texas. This companion provides not only useful facts and numbers, but ideas for how to proceed in other states.

Finally, the brochure reprints in their entirety the existing ASA Standards: Basic Standards for Preanesthesia Care, Standards for Basic Intraoperative Monitoring, Standards for Postanesthesia Care and Standards for Conduction Anesthesia in Obstetrics.

Copies can be obtained, free of charge, from the ASA Office of Governmental Affairs, 1111 14th Street, N.W., Suite 501, Washington, D.C. 20005.

Ms. Lang is Director, ASA OAC.

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Notes

The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25,00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible. @Copyright, Anesthesia Patent Safety Foundation, 1988.

The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by the APSF.

APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W. Dekle Rountree Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey B. Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.

Newsletter Editorial Board: John H. Eichhorn, M.D., Stanley J. Aukburg, M.D., Jeffrey M. Beutler, C.R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood

Address all general, membership, and subscription correspondence to:

Administrator Anesthesia Patient Safety Foundation

515 Busse Highway

Park Ridge, IL 60068

Address Newsletter editorial comments, questions, letter, and suggestions to:

John H. Eichhorn, M.D. Editor, APSF Newsletter; Dept. Anesthesia

Beth Israel Hospital, DA-7 1 7 Boston, MA 02215

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