Volume 4, No. 2 • Summer 1989

Safety and the Study of Anesthesia Incidents; Where Are We Now An Australian Perspective

John Williamson, EEA.R.A.C.S.

Following Flanagan’s pioneer work (stimulated by the ideas of Galton) with the application of his “critical incident” analysis (1), Cooper and colleagues in 197S(2) were the first to expose anesthesia to the power of this technique. Since then, we have come a distance, made some blunders, and learned a few lessons. A decade of international anaesthesia experience with such incident analyses(3-7) is not a had time to stand back, hopefully with a cold but not single eye, and look ourselves, and this approach to anaesthesia safety, over.

Human Error

To some of us, who entered anaesthesia practice when admission of error by surgeons was unthinkable, and by anaesthetists untenable, a revolution in anesthetists’ attitude has occurred. We are now beginning to acknowledge that just like the rest of the human race we anesthetists err constantly, repeatedly, and naturally. In fact, as Allnutt reminds us in an elegant paper (8), the learning process depends upon such erring, and has always done so: “. . . all human beings, without any exception whatever, make errors and … such errors are a completely normal and necessary part of human cognitive function.”

The critical incident technique (CI) has helped to foster this international advance m maturity among anaesthetists. CI has enabled us to re-discover that most error (about 70-80%) in our business as in every other occupation so far studied (1,9) is human error. (2,4) (This includes much so-called “equipment failure, which is really human error “at a distance” e.g. misuse, inadequate maintenance, etc.) Has there ever been a better example of rediscovery of the wheel?!

To err is human; To record it is fine!

Nevertheless, this attitude change is a giant step forward for safety improvement in anaesthesia. Until we acknowledge the existence of our own errors, only then can we hope to be* to (a) record them, (b) analyze them, and (the “punch fine”) develop corrective strategies (3) that will eliminate or reduce their recurrence. The anaesthesia world now seems to be on the way to biting these two “bullets” (error acknowledgment, and error recording), and indeed may at present be showing the way to other medical specialties in this regard.

The “Australian Incident Monitoring Study” (AIMS)

Just how to record and analyze these recurring human errors anonymously, validly, and continuously, especially in the face of threatening medicolegal activities, is the challenge with which many countries (including Australia) are presently grappling. Australia, with the cooperation of New Zealand, has as part of the newly created Australian Patient Safety Foundation (APSF) (10) recently launched AIMS (11), following an introductory workshop held in Brisbane in May of this year. Preliminary nation-wide Australian data from AIMS will be presented at the next AGM of the Australian Society of Anaesthetists.

From an Australian ten year overview position it is now possible to perceive some other encouraging trends as well as some present and looming challenges associated with incident reporting.

Encouraging Trends

(a) From its inception in anaesthesia (2), CI has correctly “fingered” the most common day-to-day threats to patient safety the world over, via: accidental breathing circuit disconnection, wrong drug administration (“actual” and “judgmental”), and endotracheal-tube-related problems. Disconnect alarms (“corrective strategy”) are saving lives and brains now; interestingly the value of the “obvious” step of labeling syringes remains unclear at present, at least in Australia; it is hoped further AIMS data will assist with evaluation of this strategy. It is worth noting that incident studies have already shown that the similarities of anaesthesia error vastly outnumber the differences, the world over, irrespective of country of training or practice. We are all human, and all rather alike!

(b) The studies have begun to dispel some formerly cherished but dangerous anaesthesia myths (e.g. “anaesthetists must never change during the administration of anaesthesia” (12), and “only inexperienced or junior anaesthetists are likely to intubate the esophagus and fail to recognize it.” (13)).

(c) The successful introduction of incident reporting into most Departments of Anaesthesia has the happy effect of increasing mutual trust among clinical staff who work within it. (4) As the study “bites” into safety improvement within the Department, as measured by the regular feed-back meetings, “esprit-de-corps” is enhanced, morales lift, and individuals come to recognize that their colleagues no matter how “exalted” make the same mistakes, and suffer from the same limitations as they do! And, of course, the vast majority of these incidents produce no patient harm whatever an significant CI attribute. (14)

(d) Experience and/or supervision is the anesthetists most valuable commodity for the safety of his or her patient. (3,4) Indeed inexperience is dangerous (15) a clearly signposted warning for all senior and teaching anaesthetists.

(e) Incident studies would appear to be enhancing the intelligent selection of monitoring devices from among the bewildering array offered to us these days. Sane monitoring guidelines currently being attempted in several countries (including Australia) (17) may be expected to be usefully influenced by future data from incident reports.

Some Current Challenges

(a) Few problems associated with reporting one’s incidents loom as large as the anonymity and medico-legal threat. The anesthetic literature is becoming increasingly dotted with publications (many of them unhelpful) related to this problem. Hopefully most countries will have learned something from the bitter American experience, where behavior by some legal practitioners has become actually counterproductive to patient safety

In Australia at present, legislation is in place within four of our seven States, which protects the confidentially of the voluntary report to anesthetic mortality and morbidity committee; similar legislative protection is currently being sought for AIMS (at Federal level). The writer believes that anaesthetists must now direct their efforts toward disarming aggressive medico-legal tendencies with the hard data of validated patient safety improvement, rather than the endless and capitulative tack of underwriting expensive insurance premiums, based as they are in many cases upon clinically nonsensical medico-legal precedents. We know our business better than lawyers, and we place the safety of our patients above anything else. In the meantime AIMS continues to liaise closely with the various Australian medical protection societies, and looks to constantly upgrading its anonymity safeguards, using its electronic capabilities.

(b) Morgan has emphasized the value to training and education, of broadening the scope of anaesthesia incident reporting to include “interesting and/or unusual” anesthetic experiences. (18) AIMS is presently addressing the formidable problem of classifying and incorporating this considerable body of data, but its value is promising. Future dispersal of such pertinent information will be assisted by ASA’s existing national electronic Anesthetic Bulletin Board Service (“ABBSIN’), based on the Royal Adelaide Hospital a service which is already in extensive use by the AIMS network.

(c) Safety in anaesthesia is certainly “the flavour of the month” in Australia and New Zealand at present, with meetings, themes, journal issues and workshops devoted to this topic appearing monthly. We need to keep our efforts directed along practical, clinical lines.

There is now a population of anaesthetists-in-training in this country who have never administered an anesthetic to a patient without using an army of expensive monitoring equipment (e-g. noninvasive automatic sphygmomanometer, pulse oximeter, ECG, capnograph, disconnect alarm, oxygen analyzer, peripheral nerve stimulator, temperature probe!). A fearful tendency is now reasonable for the assumption that all is well with the patient if no alarm sounds, and/or “the displayed numbers” are “O.K.”. Teachers beware!

(d) One of the greatest “on-the-ground” difficulties with incident reporting is the initiation of enthusiasm and compliance among colleagues to submit reports (“Oh no! Not more paperwork!”). The current design of the AIMS report form represents many months of thought and trial, to simplify its accurate use; and already preliminary usage has suggested improvements. It is now attested Australian experience that those anaesthetists who initially will not submit reports (“I don’t have any incidents”!), not infrequently have the greatest need to do so! AIMS relies principally upon the enthusiasm of its appointed representative in each locality (person-on-the-spot, POS (1)), and the regular feed-back of anonymous data (both local, and down-loaded national) by the POS to his or her Departmental colleagues. The future possible automation of anaesthetic records on a real-time basis should also reduce the number of incidents lost through genuine human forgetfulness.

(e) Our preliminary data is beginning to identify a subgroup of incidents which are dearly “surgeon initiated” (e.g. surgical equipment absence or failure, thoughtless alteration of surgical procedure during operations, sudden list order changes, etc.). There appears to be both a need and an opportunity for us to positively influence surgical safety; this will require tact with firmness but first hard data.

So with all its present limitations and yet-to-be-discovered problems, the future of incident reporting in anaesthesia, as a tool for improving the already high level of patient safety, looks encouraging. As further careful data is collected and analyzed, we may reasonably anticipate an increasing ability for nations (including hopefully third world countries) to be able validly to compare their safety studies (scarely possible up to now), with all the attendant advantages that will permit. Additionally a descalation of prevailing unfriendly medico-legal activities should be possible; but there are no shortcuts! As Karl Popper has observed, “The Truth is hard to come by”!

Dr. Williamson, Queensland Australia, is Co-ordinator of the Australian Incident Monitoring Study.


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