Volume 1, No. 3 • Fall 1986

U. Penn Organizes to Maximize Safety

Stanley J. Aukburg, M.D.

The University of Pennsylvania Department of Anesthesia has adopted a multifaceted approach to the management of anesthetic risk. Our goal is to provide the safest possible environment for anesthesia and surgery in an affordable manner. The realities of the malpractice liability environment forced the inclusion of liability costs in our cost-benefit ratio analyses, because our Department has multi-layered malpractice liability coverage with a substantial self-insurance component. Our approach is based on information available in the literature supplemented by reports provided by three in-house committees.

1. The Department is represented at the Medical Board’s Medical-Legal Committee and the Clinical Practices Malpractice Underwriting Committee. Pertinent information (type of case, problems posed, weakness in defense, errors made, etc.) are presented at periodic intervals to the attending and resident staff. The cases discussed are not just anesthesia-related, but include any and all cases where there is a point to be made in the area of risk management. How these cases might apply to our practice is also explored.

2. There is an ongoing Quality Control Program, wherein certain aspects of our practice are scrutinized to discover compliance with and effectiveness of regulations. Areas that need improvement are reported. The reports are presented to the Anesthesia Staff on a monthly basis. This Quality Control Program is complemented by another Department committee which reviews all operative deaths on a monthly basis. A formal report is made on all deaths that occur within the first 48 hours of surgery, or regardless of the time if anesthesia is deemed to be implicated in the demise of the patient.

3. There is an Incident Report System for anesthesia currently in place which requires the reporting of a number of potential and actual problems. These include, but are not limited to, 1. drug administration errors, 2. blood administration errors, 3. myocardial infarction within the first two post-operative hours, 4. cardiac arrest in the OR or RR, 5. dental complications, 6. bums or pressure sores, 7. cancellation of surgery after the patient has arrived in the OR, 8. iatrogenic patient injury, and 9. at the physicians’ discretion. These reports are submitted to the Department chairman and are handled as Department business or passed on to a joint committee of the Medical Board and the Clinical Practices Executive Committee if the problem is more involved.

Benefits that have accrued from these reporting mechanisms include improved awareness by all staff and improved charting and record keeping. The end result should be better patient care. The information gained from the-se sources, in addition to helping establish priorities, proved very useful in demonstrating to the administration the need to provide improved monitoring and anesthesia delivery equipment in the OR’s.

The most serious mishaps so far reported invariably include a period of hypoxia in their etiology. These were frequently related to accidental hypoventilation. We found that anesthesia mishaps and “near misses” were no more likely to occur during major surgery than during minor “noninvasive” procedures. Similarly, they were no less likely to occur in ASA Class I patients than in sicker patients. Furthermore, patients receiving regional anesthesia with sedation were at as high a risk as those receiving general anesthetics. It was dear that our existing procedures including routine continuous use of a precordial stethoscope and continuous monitoring Of F]02 were not sufficient to ensure lowest possible risk. Therefore, devices designed to reduce the likelihood of hypoxic incidents were sought for all anesthetizing locations.

Non-invasive monitors of respiratory function were first introduced to our institution in 1978 when it was decided to include infra-red C02 analyzers with continuous wave form display in all physiologic monitor purchases for the operating room. In 1979, we began to specify airway pressure disconnect and overpressure alarm in all anesthesia machines purchased. In 1983, 02 analyzers switched by an anesthesia machine main switch were added to our specifications. Finally, in 1985, pulse oximeters were purchased for every anesthetizing location.

Installation of all equipment was completed early this year. Staff and residents find the equipment easy to use. Many situations in which unsuspected ventilatory insufficiency or significant arterial desaturation occurred were revealed by the monitors before clinical signs developed. They have been reported to our internal screening groups. Examination of statistics looking for reduction in the incidence of actual complications will take place at intervals in the future.

Organization of alarm presentation and prevention of distracting false positive alarms have been set as our next priority.

Dr. Aukburg is Associate Professor of Anesthesia, University of Pennsylvania, and a member of the APSF Newsletter Editorial Board.