Anaesthesia Patient Safety Symposium 2023

Virtual Event
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“Advancing Anaesthesia Patient Safety Together”

Join us at possibly the only conference in this region dedicated to education and learning of anaesthesia patient safety!

APSS 2023 will bring together global and local leaders and practitioners committed to improving patient safety. Through sharing of safety-related news, ideas and opinions among the multi-disciplinary perioperative team members and other stakeholders, the patient safety may be further advanced to drive the best possible patient outcomes.

Featured Presentations

Plenary 1 – The Evolution of Patient Safety in Anaesthesia, Its Future Direction and an Introduction to the Anaesthesia Patient Safety Foundation

Moderator: Marzida Mansor MD, M.Anaes, FAMM, FAMS
Daniel J. Cole MD

Patients want to be able to trust that the healthcare they receive is safe, reliable and meets quality expectations. According to the World Health Organization “an estimated one in 10 patients is subject to an adverse event while receiving hospital care in high-income countries” and “134 million adverse events due to unsafe care occur in hospitals in low- and middle-income countries, contributing to around 2.6 million deaths every year.”

Perioperative patient safety focuses on how we deliver care in a way that prevents harm from the processes of care, and, accordingly, our focus is not just on medication safety and airway management but integrated systems of care that decrease risk unique to a particular patient (e.g., brain health, myocardial injury after non-cardiac surgery, acute kidney injury).

Plenary 2 – Promoting a Culture of Anaesthetic Critical Incident Reporting: Impact on Safety Culture and Patient Safety

Moderator: Teo Shu Ching MD, Mmed
Jeffrey Cooper PhD

Is Reporting Anaesthetic Critical and Safety Incidents Useful?

Reporting incidents of actual or potential harm to patients or workers is common in most healthcare facilities throughout the world and believed to be an important activity for improving patient and worker safety. Yet, there is little evidence of the effectiveness of Incident Reporting Systems (IRS) to achieve those goals. We will examine what makes an effective IRS, what elements of local safety culture impact the rate of incident reporting, how incident reporting may affect culture and what actions can be taken to improve the usefulness of reporting.

Reducing Medication Errors in Operating Room: The Best Practices

Elizabeth Rebello MD, FASA, CPPS

Medication errors are known to be a preventable threat to patient safety. The 2022 World Health Organization (WHO) World Patient Safety Day Global virtual event was dedicated to “Medication Without Harm” to increase awareness of these incidents.

This presentation will highlight best practices regarding medication safety. There will be a focus on feedback and constraint mechanisms in the medication administration process, on issues involving the labeling of syringes and vials in the perioperative environment, and on the use of smart pumps. Participants will be able to Identify ten medications that have been labeled as high alert or have been known to have produced a significant number of adverse events and understand the importance of standardizing drug concentrations.

Perioperative Deterioration: Early Recognition, Rapid Intervention and the End of Failure to Rescue

Steven Greenberg MD, FCCP, FCCM

Authors of the anesthesia closed claims database, recently suggested that failure to rescue events occurred in 1 of 5 claims for those patients suffering from severe permanent injury or death.¹ Claims generally encompassed diagnosis and treatment of postoperative respiratory depression, cardiovascular and respiratory issues due to patient comorbidities, postoperative hemorrhage and spinal/epidural hematoma.¹ The likely etiologies of these poor outcomes include ineffective communication and human factors involving decision making, time management, situational awareness, leadership and teamwork. A recent review on failure to rescue suggested that over 60% of perioperative cases were preventable² and due to failure to recognize physiologic deterioration, failure to monitor, delay in escalation and failure to make a definitive diagnosis.

To address failure to rescue in a timely fashion, several early warning system models have been developed to alert healthcare professionals of patients who are deteriorating.³ Many of these systems use scoring mechanisms that are generated from the integration of physiologic data captured through the medical record. These scoring systems are often incorporated into a clinical algorithm that alerts providers to assess and treat the potential deteriorating patient.³ Limitations of these systems include inaccurate data input from providers, lack of an effective efferent limb response (either inappropriate or inefficient), and lack of readily available cognitive aids at the bedside to help providers complete the assessment and treatment tasks.

Newer system designs may incorporate artificial intelligence and machine learning to capture signal patterns involving changes in physiologic vital signs that may later lead to patient deterioration and harm. These changes could be specific for a determined clinical scenario to customize the approach for the individual clinical provider. Using audio-visual decision support that is not distracting to the provider may lead to a more real time alert to someone who may be deteriorating. The following lecture will discuss the clear and present danger of perioperative clinical deterioration and some of the proposed modalities in which to reduce unwanted harm to our patients.

References:

1. Kent CD, Metzner JI, Domino KB. Anesthesia hazards: lessons from the anesthesia closed claims project. Int Anesthesiol Clin. 2020;58:7–12.
2. Lin D, Peden C, Langness S, et al. The Anesthesia Patient Safety Foundation Stoelting Conference 2019; Perioperative Deterioration-Early Recognition, Rapid Intervention and End of Failure-to-Rescue. Anesth & Analg 2020; 131; e155-199.
3. Green M, Lander H, Snyder A, Hudson P, Churpek M, Edelson D. Comparison of the between the flags calling criteria to the MEWS, NEWS, and the electronic Cardiac Arrest Risk Triage (eCART) score for the identification of deteriorating ward patients. Resuscitation. 2018;123:86–91.

Perioperative Deterioration: Learning from the Anaesthesia Closed Claims Project and Registries

Karen B. Domino MD

The aim of the Anesthesia Closed Claims Project is to improve perioperative patient safety by the study of adverse events in closed claims collected at participating malpractice insurance organizations in the U.S. The project is funded by the Anesthesia Quality Institute, the patient safety component of the American Society of Anesthesiologists. The lecture will briefly describe study methodology, present an overview of perioperative injuries and their causes, describe judgment problems with difficult airway management, failures in anesthesiologist situational awareness, communication failures resulting in patient injury, aspiration of gastric contents, and adverse events associated with acute pain management.

Speaking Up Across Hierarchical Gradients: Overcoming the Barriers

May Pian-Smith MD, MS

Dr. Pian-Smith’s research has focused on “speaking up” across hierarchical gradients, with the goal of improving education, enhancing the role and responsibility of all members of care teams, and supporting safety culture. This highly engaging presentation will include videos and audio recordings of simulation training sessions and experiments designed to train anesthesia providers to speak up effectively during critical events or when there is disagreement about clinical plans. Participants will learn language techniques to invite collaboration, many with roots in social sciences and organizational behavior.

Effective Perioperative Handovers: Getting Them Right

Meghan Lane-Fall MD

Transfusion errors include a wide range of events, from ABO incompatibility, infection-related complications, specimen errors, and over-transfusion. The discussion will include a review of the prevalence and etiology of perioperative transfusion errors. Components of hemoviligence will be reviewed including safety initiatives, information technology resources, and other best practices to avoid transfusion errors and transfusion-related adverse events.