Volume 3, No. 3 • Fall 1988

Patient Safety Key Theme of 9th World Congress

John H. Eichhorn, M.D.

“Vigilance’ was the theme of the 9th World Congress of Anesthesiologist’s nx2fing, May 22-28 in Washington, IDC. Accordingly, anesthesia patient safety was one of the many topics featured throughout the presentations of the Congress.

Thirty-one papers on patient safety and risk management were presented in two sessions during the week. Subjects ranged from the flammability of tracheal tubes exposed to laser to a discussion of whether or not dantrolene prophylaxis in malignant hyperthermia patients is really necessary. One paper suggested that small amounts of water taken orally, even in the immediate preoperative period, had no effect on the risk of acid aspiration.

A comprehensive report of an occurrence screening program in a major anesthesia training center was presented. Nearly 7,000 cases were screened with a comprehensive check-6t tool. The incidence of cardiac arrest during anesthesia was 0.07% and the incidence of intraoperative death was 0.04% while perioperative deaths accounted for 0. 16% of the cases. The check-list tool was felt to be very sensitive and specific for picking up both these major and a long list of relatively minor anesthesia complications.

Other papers discussed the use of an outcome index to measure the quality of care in anesthesia. There were studies of the incidence of cardiac arrest associated with spinal anesthesia and associated with death on the operating table over the last 25 years, both these studies coming from Japan. There was a discussion of the prevention of major intraoperative anesthesia accidents through minimal safety monitoring. Discussion was presented regarding the hazards of injections into intravenous tubing and a paper regarding protocols to help minimize drug administration errors was also very well received.

Panel Discussions

Two panel discussions on anesthesia patient safety were presented combining to create an all day session. Dr. I.B. Cooper reviewed studies on anesthesia mishaps, noting that there are a wide variety of mortality and morbidity statistics from different studies over different time periods and using different techniques. He suggested that human error accounted for an avoidable cause of anesthesia mishap in at least half the reported cases. He detailed the “mishap process” which involves human error associated with other factors, such as a decrease in vigilance and a deficiency in human factors, such as equipment design, all combined as a coincidence in time to yield an anesthesia accident.

Dr. I.B. Forrest presented a discussion of the relative risks of anesthesia from his studies in Canada. Dr. D.M. Gaba presented a discussion of human error. He stressed the role of anesthetist bias in the development of problems during anesthesia, in the sense that there is a tendency to assume that things are air tight until it is patently obvious that they are not. He stressed that it is important to recognize that problems will occur during anesthesia and that there needs to be improved “rule-based” responses. He suggested that there should be a redundancy in monitors and alarms and more training in how to deal with emergencies. This will result from an improved knowledge base coming from increased education and possibly the assistance of artificial intelligence in the future.

Fatigue Data Shown

An extremely interesting discussion of fatigue and vigilance was presented based on experience in the American military. While overall performance on motor tasks can remain relatively near baseline for up to 18 hours, it was noted that there can be a decrement in vigilance (decreased efficiency, more incorrect responses, and slower responses when correct) starting as soon as 30 minutes into a task with a marked decrease at two hours of a continuous task. It was noted that this was why there are four-hour shifts in the extremely high vigilance tasks in the military. It was suggested that all these factors are intensified following a period of sleep deprivation. Discussion of the concept of sleep debt and the need for relatively long unbroken periods of sleep to recover from this debt illustrated why broken sleep or intermittent naps are insufficient to restore performance after sleep deprivation. Potential applications to the current concerns about the length of working hours for anesthetists were discussed.

What Makes a ‘Good’ Anesthetist?

The selection and training of anesthesiologists was discussed at length and an analogy was made to the same processes for commercial pilots. Extensive discussion took place regarding potential predictors of success as an anesthetist and the final conclusion was that it is extremely difficult if not impossible to accurately gauge who will make a good anesthetist. Aspects of training of anesthetists to maximize safety in practice were discussed.

Several presenters from around the world discussed features, such as the quality of care in the United Kingdom, standards of practice in the Netherlands, monitoring of a healthy patient in Switzerland, the role of the anesthesia machine in the Federal Republic of Germany, and also problems in funding of anesthesia safety programs.

The panel sessions were wrapped up with a session by Dr. E.C. Pierce, Jr., President of the APSF, on the prevention of anesthesia mishaps.

Throughout the World Congress, there was a patient safety booth operated among the exhibits at which information about the APSF and its safety efforts and programs was available to all Congress attendees.

Dr. Eichhorn is Editor of the APSF Newsletter.