Letters to the Editor:

Potential Hazard of Locked Cart

To the Editor:

I want to echo the comments of Martin Bogetz, MD, in the Summer 2001 APSF Newsletter. Our hospital is involved in a pharmacy-initiated trial of an anesthesia medication storage system. This system provides an anesthesia cart with a locking mechanism to secure medications and supplies. Unfortunately, the system has suffered unexpected, complete system failures rendering the clinician unable to obtain any medications or even medical supplies (e.g., endotracheal tube). In my opinion, this system is inherently dangerous. Hospital pharmacists and manufacturer representatives have cited new JCAHO policy as a justification for their system. In my opinion, these JCAHO-initiated attempts to secure medications in the OR environment may prevent good medical care and should be systematically investigated. I ask that the APSF devote sufficient resources to investigate these developments and interact with governmental organizations to protect patient safety.

Daniel Yousif, MD
Elmhurst, IL

Legal Implications of Automated Records

To the Editor:

In the Summer 2001 APSF Newsletter several authors discussed an automated anesthesia record keeper. Many anesthesiologists will receive this concept with trepidation because of concerns unrelated to patient safety and only lightly touched upon by the authors.

The anesthesia record serves, among other purposes, as a legal document which can be used to prove malpractice. Our legal system being in its current state, anesthesiologists must consider their own legal safety in keeping an anesthetic record.

Many anesthetics produce at least one blood pressure, heart rate, or other hemodynamic value considered abnormal. Frequently these values quickly return to normal with no intervention. Handwritten anesthesia records traditionally note vital signs every 5 minutes; this allows the anesthesiologist to record a selected value within the 5-minute period. This choice reflects medical, ethical, and legal considerations. Most anesthetics are associated with good outcomes.

By eliminating this editing function, automated systems will vastly increase the number of abnormal values in every anesthetic record. The consequences will be that those few anesthesia records that become evidence in malpractice actions are far more likely to include abnormal values. While a single abnormal value in the course of an operation is not likely to be associated with a bad patient outcome, explaining this in a deposition to attorneys with a vested interest in proving otherwise can be an experience few of us want to repeat.

It is unfortunate that malpractice litigation in this country has done a poor job of compensating patients who experience a bad outcome (patients must prove malpractice or they collect nothing), removing poor practitioners (all physicians, good and bad, are insulated by malpractice insurance), or improving medical practice (funds are diverted from clinical studies and patient care to paying insurance premiums). Anesthesiologists can hardly be blamed for looking askance at a technology that, while promising to improve quality and cost of care, puts them at greater risk for malpractice loss.

Samuel Metz, MD
Philadelphia, PA