Patient Safety Again to be Featured at ASA Annual Meeting

Gerald L. Zeitlin, M.D.

Anesthesia patient safety continues to be a major topic of presentations and discussions at the American Society of Anesthesiologists annual meeting, to be held this year in Los Vegas, October 19-23. After explosive growth of interest in this area during the preceding two years, in 1989 there were over I 00 scientific presentations in the section on Patient Safety, Epidemiology, and Education. The pace continues unabated this year with 98 presentations scheduled in this area alone

Refresher Courses

In the Refresher Course selection this year, on Friday, October 19, Dr. J. Ehrenwerth will speak on ” Electrical Safety in the Operating Room.” later in the same room, “The Safe Level of Hemoglobin: Is Anemia ‘In’?” is the topic of Dr. L. Stehling. Dr. C. Vacanti will present “How Quality Assurance and the Peer Review Process Can Help Your Department” and Dr. E Cheney, Chairman of the Committee on Professional Liability, will follow with “The ASA Closed Claims Study: Lessons Learned.” On the second day of the Refresher Courses, Dr. M. Bishop will present “Bronchospasm: Managing and Avoiding a Potential Anesthetic Disaster.”

A particularly valuable Panel Discussion is scheduled for Sunday afternoon. Dr. J. Benumof of San Diego will chair a panel on “The Difficult/Impossible Airway: Catastrophes and Solutions.”

Scientific Sessions

Scientific sessions on safety, epidemiology, and Education number five with oral presentations Monday, October 22, in the afternoon and Tuesday both in the morning and afternoon. Poster sessions will also be Tuesday at both times.

Among the anticipated presentations, the flow of valuable information from the ASA Professional Liability committee’s Closed Claims study continues. In a paper based on 1,541 claims in the database, only 4% were found to be specifically related to the use of anesthesia equipment. Of these, nearly one half were due to misuse of equipment which supports previous findings that in the vast majority of cases, human failure causes the adverse outcomes which lead to malpractice suits.

Two other studies investigated human behavior and fatigue in the operating room. In the first, the investigators looked at the effects of noncognitive variables (motivation, interpersonal skills, and values) on clinical performance. Collecting and analyzing the comments of the faculty on the behavior of residents in five anesthesia departments, the authors found that conscientiousness on the part of the trainee was the trait which best predicted both performance and the avoidance of critical incidents.

In the other related study, the authors exposed residents to critical incidents generated by an anesthesia simulator. The responses were compared to those of both teaching faculty and private practice anesthesiologists. It was found that the more experienced practitioners detected and corrected potentially serious problems more quickly. However, even within the group of experienced practitioners there are marked variability and even a few outliers. This supports the thesis of Dr. T. Vitez and his complicated Las Vegas Model Clinical Competence quality assurance program, which suggests that clinical outliers must be identified and then either retrained or redirected.

There is a study of “Reported Significant Observations” (RSO’s) in which all the members of an anesthesia department in a single hospital reported anonymously their deviations from conventionally accepted safe practice (a surprisingly wide variety of types of occurrences). Eighty-three percent were considered ” preventable and 20% involved potentially lethal events. RSO’s constituted a broader concept than Dr. 1. Cooper’s now classic “critical incidents” but the outcome of ” work strikes a similar chord to that pioneer work.

Examples of other interesting research that will be presented are: the rate of intravenous injection of midazolam does not appear to affect its potential to produce hypoxemia; needles can be recapped for reuse without risk of contamination if injections are made into the ports of intravenous tubing farthest away from the patient; in patients who had suffered anaphylacticrea6onstoanestheficdruSs,skintesting with other drugs accurately predicted a safe choice of medications for a potential subsequent anesthetic; proper use of commonly used predictors of difficult intubation, such as ability to see the pharynx preoperatively, wig reduce the incidence of unpleasant airway surprises after the patient is anesthetized; a study of “Recovery Room Impact Events” (intraoperative occurrences that impact PACU care) strongly supports what has be-en felt intuitively serious complications were reduced when the pulse oximeters were introduced into all the operating rooms. Also, an update (showing changing patterns over the decades) of the classic Medical College of Virginia study on intraoperative cardiac arrests will be presented.

The meeting section on Equipment, Monitoring, and Engineering Technology will also be extremely active. There will be three poster and four oral presentation sessions with a total of 133 scientific papers. Several have implications or polential applications for anesthesia patient safety.

Outlined here is only a representative sampling of the safety-related material available at the ASA meeting. Further details are available in the formal meeting program. Finally, be sure to visit the Patient Safety Booth in the Exhibit Hall for more ideas and several samples of information that can be taken back to practitioners’ home departments for individual application.

Dr. Zeitlin, Lahey Clinic, Burlington, MA, is one of the Associate Editors of the APSF Newsletter.