Episode #153 How to Keep Patients Safe During Anesthesia Care: A Primer

June 6, 2023

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

We have an all-new show today. Scott Blaine, a senior anesthesia resident, joins us to talk about tips for keeping patients safe for new anesthesia trainees.

Here are the tips that we review on the show today:

  1. Label syringes and infusion bags prior to them leaving your hand. Make distinguishing labels on bags or syringes that could look similar. Don’t open boxed syringes that could look similar (e.g., epinephrine and calcium at our institution look very similar once unboxed).
  2. Read vials as you’re drawing meds up. As an intern there is a pharmacist and a nurse in between you and giving a med to a patient. In the OR it will often be just you.
  3. Participate in time outs. Wrong side surgery or blocks are preventable.
  4. Using checklists and references. I made a google doc with dose ranges and common contraindications. Checklist for setting up the room so you don’t forget necessary equipment.

Here is a complete list of the APSF Patient Safety Priorities.

Here are some medication safety resources:

Here is a good resource about communication and building relationships in the operating room and across the drapes.

Check out the Emergency Manuals Implementation Collaborative which focuses on adoption and use of emergency manuals to enhance patient safety. Using emergency manuals and checklists is an important part of keeping patients safe during critical perioperative events.

Here is a link to the book Scott mentioned on the show today, The Checklist Manifesto, by Atul Gawande.

Thank you to Scott Blaine for joining us on the show today. When he is not recording podcasts for the APSF, he is working to keep patients safe and complete his anesthesia training at University of Wisconsin Hospitals and Clinics.

Be sure to check out the APSF website at https://www.apsf.org/
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Questions or Comments? Email me at [email protected].
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© 2023, The Anesthesia Patient Safety Foundation

You are listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We’re bringing you the very best from the A P S F newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Ali Bechtel and I’m your host. Thank you for joining us for another show. We are so excited to have a new show for you today with a special guest. Anesthesia. Trainees provide anesthesia care throughout their training, and a foundation of patient safety right from the very beginning is critical to keep patients safe.

Before we dive into the episode today, we’d like to recognize Medtronic, a major corporate supporter of A P S F. Medtronic has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Medtronic. We wouldn’t be able to do all that we do without you.

Our guest on the show today is an anesthesia resident who is committed to anesthesia patient safety, and I will let him introduce himself now.

[Blaine] Hi, Dr. Bechtel. Thanks for having me on the podcast. My name is Scott Blaine. I’m in my final year of anesthesia residency at the University of Wisconsin, and after graduation, I’ll be joining a private practice group.

[Bechtel] And what got you first interested in anesthesia patient safety throughout your training?

[Blaine] I think it was as a first year. Getting used to the hospital system, entering orders for patients on the hospital floor. There’s many steps in between you deciding to give a medication and the actual medication delivery.

You would place an order in the electronic medical record, which was then reviewed by a pharmacist. And then a nurse who would usually verify with a colleague prior to actually administering that medication. As we all know in the operating room, this model isn’t feasible. Um, and we will often need to administer medication, you know, within seconds of, of deciding to do that.

And I think this introduces a significant amount of potential error. Uh, and that’s part of our job to manage. And so, uh, Coming through anesthesia training, I was always looking for ways to mitigate that risk of error in our job and, uh, be better at, um, avoiding those types of errors.

[Bechtel] Oh, that’s wonderful.

And that actually kind of leads us to our idea for the show today. When we started talking, we said, well, what would be a really good way to introduce new anesthesia residents or any trainees in in anesthesia? Two anesthesia patient safety right from the very beginning. And so we had this idea to say, what are some anesthesia patient safety tips or tricks for new residents? Really simple things to keep in mind from the first minute you step into the operating room to help keep patients safe. So Scott came up with a list of ideas for us, which is great. And, what we are going to do on the show today is just go through some of these tips and tricks, um, and talk about what it looks like in the operating room, and then some resources that you can use to help keep patients safe in, in each of these different areas.

So, Scott, let’s start with the first one.

[Blaine] The first tip and trick that I always like to remind residents, new residents is that labeling both syringes and infusion bags is the first step to avoiding medication errors.

[Bechtel] Is there a certain way that you like to label your syringe or infusion bags or what’s really important when you’re doing that?

[Blaine] I do, yeah. I like to place the labels perpendicular to the length of the syringe so that when you set them down on the cart, uh, no matter which way it’s facing, uh, you’ll always see the color of the label so that you don’t mistake one syringe for the other. I also like to place distinguishing. Labels on the infusion bags.

Um, at our institution we have plain white labels that will have black texts on them. Um, but if I have two infusion bags in the same room, I’ll be sure to put some distinguishing color or some distinguishing feature on the bags so that I don’t mix them up.

[Bechtel] And then you had another good point about how some of the boxed syringes that are used in emergency situations, in the boxes, they look quite different and they’re labeled very clearly, epinephrine or calcium.

But when you take them out of the box, the syringe itself looks really similar. So if you’re not using it right away, it’s really helpful to just leave it in the box.

[Blaine] Yes, absolutely. And this is something that I think comes up at most institutions. There are all kinds of publications and. Trying to address the quote unquote lookalike medications. And like you said in the box, they do look, uh, they are distinguishable from each other. But, um, you know, an example that we often find is epinephrine and calcium, both of which are medications you could be using in a hurry and an emergency. Um, and ones out of the box. They both come in clear syringes with yellow caps that look, uh, much too similar, uh, for comfort.

[Bechtel] I agree. And then our second tip and trick is related to this one. So do you want to go ahead and tell us about that one?

[Blaine] Yeah. The second tip is to read the vials as you’re drawing up the medications. I like to hold the medication in my, the medication vial in my left hand, and as I draw back on the plunger of the syringe with my right hand.

And this way I kind of have it in front of my, uh, Eyesight and I will read the label on the vial as I’m drawing up the medication and I’d be sure to, I’m sure to read the medication name, the concentration in milligrams per mil, or whatever the concentration is labeled as, uh, as well as the expiration date on the vial.

[Bechtel] That is great, and what we know is that there are a lot of lookalike medication vials there. We have a whole site dedicated to this [email protected], but it’s really important to not rely on the, what the vial looks like or what the cap color is, because those can be very similar between different kinds of medications.

But really reading that label as you’re drawing it up is really important. These first two tips are related to one of the APSF’s, perioperative patient safety priorities. Number seven, which is medication safety. Important considerations for medication safety include drug effects, labeling issues, shortages, technology issues, and processes for avoiding and detecting errors.

There is definitely a lot to think about as a new anesthesia trainee. There are some great resources from the APSF, including past articles and conferences and podcast episodes that you can check out like the June, 2021, A P S F newsletter, article by Ron Lipman. Important medication errors and hazards reported to the I S M P National Medication Errors Reporting Program during 2021 or podcast episodes 54 and 55 during which we review this article and lookalike medication vials and threats to anesthesia patient safety from medication errors. Plus, the ASA provides some guidance as well. Check out the statement on labeling of pharmaceuticals for use in anesthesiology, which was updated in 2020. I will include a link in the show notes as well. This statement includes the requirements for labeling, which includes the generic name and concentration of the medication, as well as the date and time, and prepares initials.

You may want to include the patient’s name and the route of administration as well, especially if the patient will be transferring to a different location in the hospital. Did you know that there are nine reserved colors for classes of drugs commonly used in anesthesiology, including induction agents, benzodiazepines and their antagonists, neuromuscular blockers and their antagonists, opioids and their antagonists, antiemetics, vasopressors and hypotensive agents, local anesthetics, anticholinergic agents, and beta blockers.

This standard labeling is black on the specific background for most agonist agents and black on the white striped specific background for most antagonist agent. Saxo choline and epinephrine are special medications with text that is the specified color on a black background bar on the top of a label.

There are many more important recommendations when it comes to labeling medications, so we encourage you to go check out the article. One more consideration from the statement that we want to highlight is the position of the label on the syringe. When syringes labels are placed incorrectly, they may be difficult to see or read and can lead to a syringe swap or administration dose drug error.

The recommended label placement should be directly below the gradation lines so that the scale. Medication name, concentration, and dose are all easy to see and read during administration of the medication. And I think these two tips and tricks are really important to help avoid errors or detect an error if you notice that the medication you pulled out of the drawer is not the medication that you intended to draw up, were there any clinical scenarios that came up in the operating room that you know of?

[Blaine] Like when drawing up a medication? Yeah, we, I’ve, I’ve heard stories and seen, uh, look alike vials. Most recently we had some ondansetron vials that looked very similar to the 10 milligram phenylephrine vial.

Uh, both come in one milliliter solution, um, and had a blue cap. Uh, and so as you, as you could guess, mixing those two medications up would not be, uh, a desirable mistake.

[Bechtel] Absolutely. All right. Now from here, let’s move on to our third tip and trick.

[Blaine] Yeah. The third tip and trick is participation in timeouts.

And, you know, this might seem, uh, seem that it should go without saying, but I think for anybody who would have been practicing prior to timeouts being a routine part of our day, uh, they could, they would tell you that there are stories of wrong side surgery. Um, you know, the wrong patient, getting the wrong procedure, uh, all of which.

These timeouts are intended to, uh, eliminate those types of scenarios.

[Bechtel] I agree. I think the timeout is a really important part of the procedure, but it’s also something that can be easily overlooked or just done quickly to move on and get the procedure started, but a well done timeout. This is a good time for introductions for all of the healthcare team members and their roles in the operating room.

It’s a good time to make sure that everyone is on the same page and it’s a good time to voice any concerns about the procedure, the patient, equipment, and staffing. And this one actually falls under two A P S F. Patient safety priorities, the culture of safety and teamwork. There’s actually a really great article on the A P S F website called Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety by Jeffrey Cooper from the February, 2020 A P S F newsletter.

It’s never too early to start building relationships with other members of the healthcare team and working on communication skills and the timeout is a really good chance to start doing that.

[Blaine] Absolutely. Team dynamics are so important, especially when it comes to emergencies as anyone who’s been a part of a well run code versus a, uh, code that you, uh, think wasn’t that well run.

Usually it comes down to communication and if you are, you know, at least either on a first name basis or have built some kind of rapport with the surgeon. The circulating nurse, the scrub tech, it makes for a much smoother, uh, uh, much smoother emergency should one rise.

[Bechtel] Absolutely. All right, now our next one, speaking of that, is really important in emergency situations too. So let’s talk about number four.

[Blaine] Yeah, the fourth tip and trick is using both checklists and references. So I always like to go or think back to the book by Atul Gawande, The Checklist Manifesto. I read that prior to starting residency. And I think it really hit home because he’s a prominent surgeon who is acknowledging in this book that we are all human and we all will make errors. And I think it’s part of our job to do what we can to set us up for success and to avoid, uh, these potential errors. And I think one of those, one of the things you can do to.

Avoid those is checklists. And so, I use a checklist every morning when I’m setting up the operating room. Uh, I have a pneumonic that I use to make sure that I have all my materials in the room, all the medications, my suction, all the things that I’m going to need to perform a safe anesthetic. And I use that same checklist every morning so that I know when I induce the first patient that everything that I will need is.

In the room, um, so that you’re not searching around for something. When an emergency arises, what is the pneumonic that you use? I like to use Misty Maid, so MST MAIDS. So I go through my machine check for the first m, my suction for s, t tape for the eyes, and for the ETT tube. The next M is medications, then airway, then the iv, both IV kits and fluid D for drugs, and then S for special as kind of a grab outback for everything else, like arterial line, additional equipment.

Then you anticipate new using.

[Bechtel] Oh, that’s great. This one falls under the third APSF Priority, clinical deterioration, which includes preventing, detecting, determining pathogenesis, and mitigating clinical deterioration in the perioperative period. Here are some components of this priority.

  • Early systems in all perioperative patients.
  • Monitoring for patient deterioration, which may include postoperative continuous monitoring on the hospital floor, opioid-induced ventilatory impairment and monitoring, and early sepsis monitoring and early recognition.
  • Response to the decompensating patient.

Checklist and references play a role here when they’re able to help prevent patient deterioration, or they may be used in response to a decompensating patient.

For more resources related to checklists, check out some of the [email protected]. There are articles from as early as 1990 that discuss the use of checklists for improving patient safety. More recently, in October, 2021, there was an article that covered timeout checklists in non-op operating room locations, or Nora.

There is one more great resource that I need to mention, and it is the Emergency Manual’s Implementation Collaborative, which focuses on adoption and use of emergency manuals to enhance patient safety. Using emergency manuals and checklists is an important part of keeping patients safe during critical perioperative events.

I will include a link for more information in the show notes as well. So this is just an area that has really expanded in the use of checklists throughout Anesthesia care has really helped to help keep patients safe.

[Blaine] Absolutely. And I also really like using references too, especially as a new trainee, I think there’s so many things that are new to you and unfamiliar.

Um, and so I actually made a table for myself, kind of like an Excel sheet, um, that had the common medications that we use there, their. Milligram per kilogram dosing. And then some common either adverse effects or things to be on the lookout for. Um, so that when I was in the operating room and myself, um, I didn’t have to be either searching a database to find, uh, an appropriate dosing.

I would just make notes to myself of doses that we had used in the past so that I could verify. Uh, prior to giving a medication, obviously this becomes easier the more you’ve done it and you don’t have to think about the dose for Ondansetron, but in the beginning it’s good when you’re unfamiliar with things to double and triple check prior to administering medications.

[Bechtel] Are there any apps that you used during anesthesia care as a reference?

[Blaine] Yeah, I like to use up to date, I have up to date on my phone and institution, like a login through our institution. Um, and they have a good, any medication you can search for and then it’ll have common indications for those medications and common doses for each indication.

[Bechtel] Oh, that’s great. Some other ones that we have used in anesthesia include ASRA Coags, which has recommendations for, uh, Anticoagulants and thrombolytics and the timing with neuraxial procedures, which I found to be really helpful. Uh, there’s a Pedi Crisis App for, uh, pediatric anesthesia, uh, as a reference guide.

Oh, Safe Local. Have you heard of that one?

[Blaine] Yes. I use all three of those. They’re wonderful apps. You know, I, I kind of think about. The fact that we all have these super computers in our pockets and. We, you know, in this day and age, it’s kind of incumbent on us to use the technology to our advantage. And so I think if you were to find yourself in a situation where you didn’t use something like this and you made an error, um, at least myself, I, I don’t know if I could forgive myself if I had access in my pocket to something wonderful like these apps, and then still made a mistake because I, because I didn’t use them when they’re so easy to use.

[Bechtel] Thank you so much to Scott for joining me on the show today. We have so much more to talk about, but you will have to tune in next week when we continue the conversation. If you have any questions or comments from today’s show, please email [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice.

We hope that you’ll visit aps f.org for detailed information and check out the show notes for links to all the topics we discussed today. To all of the anesthesia trainees listening to this podcast, welcome to the field of Anesthesiology. We hope that as you progress through your training, you remain committed to improving patient safety.

You might be a future recipient of an APSF research grant, or a future author of an APSF newsletter article, and we might be talking with you right here on this podcast. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation