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Preventing OR DisastersBefore They Happen
Preventing OR DisastersBefore They Happen
Rafael Ortega, MDProfessor of Anesthesiology
Rafael Ortega, MDProfessor of Anesthesiology
Boston University School of Medicine
September 11, 2010
Boston University School of Medicine
September 11, 20109:30 AM -10:30 AM9:30 AM -10:30 AM
Connecticut State Society of Anesthesiologists
Connecticut State Society of Anesthesiologists
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Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask:safety revisited. Anesthesiology 1996;84(4):965- 75.
Ortega RA: Leroy Vandam: An anesthesia journey. Journal of Clinical Anesthesia (2005) 17, 399–402
“One day, in his inimitable way, Vandam assigned Pierce the subject of “anesthesia accidents” to be given as a resident’s lecture. Years later, Dr Pierce, with others, founded one of the most influential organizations in anesthesiology, The Anesthesia Patient Safety Foundation.”
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Accident?Accident?
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Why do accidents happen?Why do accidents happen?
• Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.
Wagenaar and Groeneweg
• Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.
Wagenaar and Groeneweg
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Family Sues in Operating Room Fall
“Matriarch suffered a fatal head injury Catherine O'Donnell, was a lifelong Dorchester
resident… “
By Jonathan Saltzman Globe Staff
January 29, 2008
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ObjectivesObjectives
• To review conditions O.R. disasters have in common
• To present examples of O.R. disasters (or near disasters)
• To recommend strategies to minimize O.R. mishaps
• To review conditions O.R. disasters have in common
• To present examples of O.R. disasters (or near disasters)
• To recommend strategies to minimize O.R. mishaps
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Anesthesia RiskAnesthesia Risk
• The rates of morbidity and mortality depend on the definitions.
• Data demonstrates that risk directly attributable to anesthesia has declined over time.
• The rates of morbidity and mortality depend on the definitions.
• Data demonstrates that risk directly attributable to anesthesia has declined over time.
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Liquid Oxygen LeakLiquid Oxygen Leak
Birmingham, Alabama VA HospitalSchumacher SD et al. Bulk Liquid Oxygen Supply Failure. Anesthesiology. 2004;100:186-189.
Birmingham, Alabama VA HospitalSchumacher SD et al. Bulk Liquid Oxygen Supply Failure. Anesthesiology. 2004;100:186-189.
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It can happen to you too…It can happen to you too…
Boston Medical CenterJune 15, 2006
Boston Medical CenterJune 15, 2006
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It’s Everyone’s Business!It’s Everyone’s Business!
Chest. 2010 Feb;137(2):443-9.Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety
Am J Surg. 2010 Jan;199(1):60-5.
Factors compromising safety in surgery: stressful events in the operating room.
J Health Serv Res Policy. 2010 Jan;15 Suppl 1:48-51.Errors in the operating theatre--how to spot and stop them.
Surgeon. 2010 Apr;8(2):87-92. Epub 2010 Feb 18.
Surgical fires, a clear and present danger.
Jt Comm J Qual Patient Saf. 2010 Mar;36(3):133-42.Does teamwork improve performance in the operating room? A multilevel evaluation.
Surgeon. 2010 Apr;8(2):93-95.
Safe surgery, the human factors approach.
Qual Saf Health Care. 2010 Feb;19(1):69-73.Promoting patient safety through prospective risk identification: examples from peri-operative care
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Potential CrisesPotential Crises
• Anaphylaxis• Transfusion Reactions• Malignant Hyperthermia• Difficult Airway• Fires• Electrical Safety• Cardiac Arrest• Etc.
• Anaphylaxis• Transfusion Reactions• Malignant Hyperthermia• Difficult Airway• Fires• Electrical Safety• Cardiac Arrest• Etc.
But what do they have
in common?
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Features in CommonFeatures in Common
• Critical incidents• Reason’s Swiss Cheese• Relatively Rare• Training (and re-training) Required• Communication• Fixation Errors• Reportable• Litigation Prone
• Critical incidents• Reason’s Swiss Cheese• Relatively Rare• Training (and re-training) Required• Communication• Fixation Errors• Reportable• Litigation Prone
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What is a “Critical Incident”?What is a “Critical Incident”?
• Term made famous by Cooper.
• Defined: occurrences that are “significant or pivotal, in causing undesirable consequences”.
• Also defined as: an event that led, or could have led to a problem.
• Critical Incidents provide opportunity to learn about factors that can be remedied.
• Term made famous by Cooper.
• Defined: occurrences that are “significant or pivotal, in causing undesirable consequences”.
• Also defined as: an event that led, or could have led to a problem.
• Critical Incidents provide opportunity to learn about factors that can be remedied.
Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.
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BMC and Critical IncidentsBMC and Critical Incidents
• Root-Cause Analysis (Risk Management)
• On-line reporting
• 31-RISK Beeper (24 / 7 / 365)
• Physician Vice-President for Quality and Patient Safety
• Root-Cause Analysis (Risk Management)
• On-line reporting
• 31-RISK Beeper (24 / 7 / 365)
• Physician Vice-President for Quality and Patient Safety
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• Analyze all critical incidents (including the ones that could have led to a problem)
• Use a standardized approach to identify causes, system failures, and opportunities for improvement.
• Where was the hole in the Swiss cheese?
• Analyze all critical incidents (including the ones that could have led to a problem)
• Use a standardized approach to identify causes, system failures, and opportunities for improvement.
• Where was the hole in the Swiss cheese?
RecommendationRecommendation
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What is the Role of Simulation?What is the Role of Simulation?
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What is the Role of Simulation?What is the Role of Simulation?
• Improving on Reality: Can Simulation Facilitate Practice Change? Anesthesiology. 112(4):775-776, April 2010.
• Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation Anesthesiology . 112(4):1041-1052, April 2010.
• Anesthesiology Residents' Performance of Pediatric Resuscitation during a Simulated Hyperkalemic Cardiac Arrest. Anesthesiology. 112(4):993-997, April 2010.
• Acquisition of Critical Intraoperative Event Management Skills in Novice Anesthesiology Residents by Using High-fidelity Simulation-based Training. Anesthesiology 112(1):202-211, January 2010.
• Simulation Training and Assessment: A More Efficient Method to Develop Expertise than Apprenticeship Anesthesiology. Anesthesiology.112(1):8-9, January 2010.
• Improving on Reality: Can Simulation Facilitate Practice Change? Anesthesiology. 112(4):775-776, April 2010.
• Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation Anesthesiology . 112(4):1041-1052, April 2010.
• Anesthesiology Residents' Performance of Pediatric Resuscitation during a Simulated Hyperkalemic Cardiac Arrest. Anesthesiology. 112(4):993-997, April 2010.
• Acquisition of Critical Intraoperative Event Management Skills in Novice Anesthesiology Residents by Using High-fidelity Simulation-based Training. Anesthesiology 112(1):202-211, January 2010.
• Simulation Training and Assessment: A More Efficient Method to Develop Expertise than Apprenticeship Anesthesiology. Anesthesiology.112(1):8-9, January 2010.
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Expertise vs. Experience
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• Self-confidence• Excellent communication skills• Adaptability• Risk tolerance • Attention to what is relevant• Ability to identify exceptions to the rules• Effective performance under stress• Ability to make decisions• Quick reactions based on incomplete data
Anesthesiology:Volume 107(5)November 2007pp 691-694 Experience ≠ Expertise: Can Simulation Be Used to Tell the Difference?
Editorial - Weinger, Matthew B. M.D.
Expertise vs. Experience
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Simulation at BMC - AnesthesiaSimulation at BMC - Anesthesia
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Simulation in HealthcareSimulation in Healthcare
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RecommendationRecommendation
• Simulate, conduct drills, review strategies. Although ideal, a simulation laboratory is not strictly necessary to engage in simulation.
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Illustrative ExamplesIllustrative Examples
• Wrong Dose: Communication Error
• Missing Kidney: Communication Error
• Airway Management: Fixation Error
• Wrong Gas Administration
• Malignant Hyperthermia
• Wrong Dose: Communication Error
• Missing Kidney: Communication Error
• Airway Management: Fixation Error
• Wrong Gas Administration
• Malignant Hyperthermia
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“eight thousand of heparin”
vs.
“a thousand of heparin”
“eight thousand of heparin”
vs.
“a thousand of heparin”
Communication ErrorCommunication Error
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Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding. Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding.
Control Room aboard USS Seawolf submarine. (courtesy of www.navy.mil)
Communication ErrorCommunication Error
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Meant
Said
Heard
Understood
Done action
Closing the loop
X Not said
X Not understood
X Not done
Modified from Miller’s Anesthesia. Elsevier 2009
Not heardX
Stairway of CommunicationStairway of Communication
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RecommendationRecommendation
• Use Closed-Loop Communication whenever possible.
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The Missing KidneyThe Missing Kidney
In December 1954, Dr. Murray performed the world's first successful kidney transplant between the identical Herrick twins at the Peter Bent Brigham Hospital.
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“The Ether Screen”“The Ether Screen”
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Transparent DrapesTransparent Drapes
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Transparent DrapesTransparent Drapes
Transparent Ether Screens: The Road to New TransparencyOrtega R, Gonzalez M, Lewis K
ASA Newsletter , February, 2010
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Transparent DrapesTransparent Drapes
Transparent Ether Screens: The Road to New TransparencyOrtega R, Gonzalez M, Lewis K
ASA Newsletter , February, 2010
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Why Communication Fails in the Operating Room J Firth-Cozens
Qual Saf Health Care 2004;13:327
Why Communication Fails in the Operating Room J Firth-Cozens
Qual Saf Health Care 2004;13:327
• Team instability - different scrub nurses• Team policies about communication - proper introductions• Disallowing distractions - noise • Redundancy - allows people time to communicate• Sufficient resources - equipment • Stress – what stress?• Introverts Vs. Extroverts – many examples• Professional language - way of maintaining power?• Team meetings outside immediate task - enhancing rapport
• Team instability - different scrub nurses• Team policies about communication - proper introductions• Disallowing distractions - noise • Redundancy - allows people time to communicate• Sufficient resources - equipment • Stress – what stress?• Introverts Vs. Extroverts – many examples• Professional language - way of maintaining power?• Team meetings outside immediate task - enhancing rapport
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BUMC BandBUMC Band
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Losing the AirwayLosing the Airway
• 27-years-old male patient• Fracture jaw• Naso-tracheal intubation• Class I visualization• Difficult ventilation• Equivocal capnogram• Severe bronchospasm?
• 27-years-old male patient• Fracture jaw• Naso-tracheal intubation• Class I visualization• Difficult ventilation• Equivocal capnogram• Severe bronchospasm?
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The Tube is in the Trachea!The Tube is in the Trachea!
Leissner KB, Ortega RA, et. al. Kinking of an endotracheal tube within the trachea: a rare cause of endotracheal tube obstruction. Journal of Clinical Anesthesia (2007) 19, 75–81
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ETTForeign Body Anesthesia
Machine
Ascaris
ETTKinking
ETTDefective
TurbinateAvulsion
Chest RigiditySevere
Bronchospasm
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Fixation ErrorsFixation Errors
Human errors (1/3 of error: FIXATION)Human errors
(1/3 of error: FIXATION)
DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation.
Anesth Analg. 1990 Jul;71(1):77-82.
Equipment failures >
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Fixation Errors Types and Recommended Countermeasures
Fixation Errors Types and Recommended Countermeasures
"This and only this!" Persistent failure to revise a diagnosis
Accept possibility that first assumptions may be wrong
"Everything but this!" failure to commit to definitive treatment of major problem
Rule out worst case scenario
"Everything is OK!" Persistent belief that no problem is occurring
Artifacts are the last explanation for changes in critical values
CountermeasureError Type Description
(Adapted from Rall M, Gaba DM: Human Performance and Patient Safety, in Miller 6th edition 2007)
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A 66-year-old woman admitted to SICU after CABG.History of severe hypertension on a nitroprusside drip.
The surgeon had warned about a friable aorta.
75
100
125
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5 Minutes
She has severe hypertension…..75
100
125
150
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10 Minutes
She is pain…..75
100
125
150
175
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15 Minutes
She is anxious…..
100
125
150
175
200
75
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75
100
125
150
175
200
225
20 Minutes
Nitroprusside dose is insufficient…..
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75
100
125
150
175
200
225
>30 Minutes
Oh no!
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Initial State
A
B
C
D
Adapted from: E. Fioratou et al. No simple fix for fixation errors Anaesthesia, 2010, 65, pages 61–69
It costs 2 cents to open a link and 3 cents to close it again
Goal State
15 Cents
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2 cents to open a link x 3 = 6 3 cents to close a link x 3 = 9
Total = 15
“Lateral Thinking”
97%1 2
3
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if X (local signs) then do Y (a particular intervention).
A rule of thumb, simplification, or educated guess that reduces or limits the search for solutions in domains that are difficult and poorly understood.
Pattern Matching Machine
if X (local signs of a problem exist)
then it is probably Y (a particular condition to be managed)
or
Heuristics
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RecommendationRecommendation
• Be aware of fixation errors and strategies to prevent them.
• Be aware of fixation errors and strategies to prevent them.
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Wrong Gas: a rare eventWrong Gas: a rare event
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Incidents with GasesIncidents with Gases
Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube.Eur J Anaesthesiol. 2000 Jul;17(7):456-8.
Oxygen contamination of the nitrous oxide pipeline supply.Anaesth Intensive Care. 1998 Apr;26(2):207-9.
Failure of operating room oxygen delivery due to a structural defect in the ceiling columnMasui. 2000 Oct;49(10):1165-8.
Pollution of the medical air at a university hospital in the metropolitan Tokyo area. Journal of Clinical Anesthesia. 14(3):193-5, 2002.
Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device. Annales Francaises d Anesthesie et de Reanimation. 15(5):683-5, 1996.
Contamination of the medical air supply with oxygen: a clinical engineering incident investigation. Journal of Clinical Engineering. 15(4):295-300, 1990.
Medical air contamination with oxygen associated with the BEAR 1 and 2 ventilators. Critical Care Medicine. 16(4):362, 1988.
Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube.Eur J Anaesthesiol. 2000 Jul;17(7):456-8.
Oxygen contamination of the nitrous oxide pipeline supply.Anaesth Intensive Care. 1998 Apr;26(2):207-9.
Failure of operating room oxygen delivery due to a structural defect in the ceiling columnMasui. 2000 Oct;49(10):1165-8.
Pollution of the medical air at a university hospital in the metropolitan Tokyo area. Journal of Clinical Anesthesia. 14(3):193-5, 2002.
Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device. Annales Francaises d Anesthesie et de Reanimation. 15(5):683-5, 1996.
Contamination of the medical air supply with oxygen: a clinical engineering incident investigation. Journal of Clinical Engineering. 15(4):295-300, 1990.
Medical air contamination with oxygen associated with the BEAR 1 and 2 ventilators. Critical Care Medicine. 16(4):362, 1988.
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Fixation: Everything is OKFixation: Everything is OK
• Patient complaining of pain
• Free air the abdomen
• Cost center discrepancies
• Patient complaining of pain
• Free air the abdomen
• Cost center discrepancies
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A Close CallA Close Call
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Good IdeaGood Idea
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FDA MAUDE DATABASEFDA MAUDE DATABASE
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PROBLEMS WITH:Teamwork and Communication
Design, Construction and MaintenanceEquipment Standardization
Drug Labeling, Purchasing, Stock Control, and Delivery
Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia
Providers
PROBLEMS WITH:Distraction
Momentary InattentionForgetting
Losing the PicturePreoccupation
Fixation(Psychological Antecedents of Unsafe Acts)
The Organization The IndividualAdapted from: Reason: Qual Saf Health Care 2005;14:56–61
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PROBLEMS WITH:Teamwork and Communication
Design, Construction and MaintenanceEquipment Standardization
Drug Labeling, Purchasing, Stock Control, and Delivery
Patient Assessment and Patient Scheduling Scheduling and Coordination of Anesthesia
Providers
PROBLEMS WITH:Distraction
Momentary InattentionForgetting
Losing the PicturePreoccupation
Fixation(Psychological Antecedents of Unsafe Acts)
what goes on in the head of the practitionerbeyond a certain point—extremely difficult to
control
The Organization The Individual
Hard to Control
Controllable
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“Unsafe acts are like mosquitoes. They can be swatted or sprayed, but they still keep coming. The only effective remedy is to drain the swamps in which they breed.”
Adapted from: Reason: Qual Saf Health Care 2005;14:56–61
The SwampThe Swamp
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The GardenThe Garden
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Defenses
IncidentAccident
Management Decisions
Organizational Processes
Corporate Culture
OR Executive
Sequence begins with negative consequences of
processes :decisions regarding
planning, scheduling, forecasting, designing,
specifying, communicating,
regulating, maintaining, etc.
Error-ProducingConditions
Violation-ProducingConditions
Operating Room
Latent failures transmitted along organizational
pathways to workplace creating local conditions
that promote the commission
of errors and violations: understaffing, fatigue, technical problems, high work load, poor
communication, conflicting goals, inexperience, low
morale, teamwork deficiencies, etc.
Errors
Violations
OR Worker
Unsafe acts are likely to be committed, but
only few penetrate the defenses to produce
incidents.
Inheritors (Mosquitoes)Instigators (Swamp)
Adapted from: Reason: Qual Saf Health Care 2005;14:56–61
Stages in the Development of an Organizational Accident
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Malignant HyperthermiaMalignant Hyperthermia
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Malignant HyperthermiaMalignant Hyperthermia
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DantroleneDantrolene
Rosenberg H: Anesthesiology News March 2010
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Malignant HyperthermiaMalignant Hyperthermia
Rosenberg H: Anesthesiology News March 2010
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A. Line InfectionA. Line Infection
Ortega R, Rengasamy SK, Lewis KP: Infection after radial artery catheterization. Anesth Analg 2002;95:780-7
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AmyloidosisAmyloidosis
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Compartment SyndromeCompartment Syndrome
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Impalement of the Brain Impalement of the Brain
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Broken Needle in Aorta Broken Needle in Aorta
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Ventilator Failure 1Ventilator Failure 1
Ortega RA, Vrooman B, Hito r: Another Cause for Ventilator Failure. Anesthesiology. Anesthesiology. 104(6):1351, June 2006
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Ventilator Failure 2Ventilator Failure 2
Ortega RA. Zambricki ER. Fresh gas decoupling valve failure precludes mechanical ventilation in a Draeger Fabius GS anesthesia machine. Anesthesia & Analgesia. 104(4):1000; 2007 Apr
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Administrative Guidelines for Response to an Adverse Anesthesia Event
Journal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Febwww.APSF.org
Administrative Guidelines for Response to an Adverse Anesthesia Event
Journal of Clinical Anesthesia. 5(1):79-84, 1993 Jan-Febwww.APSF.org
• Primary anesthetist concentrates on continuing patient care.• Notify a physician responsible for supervision of anesthesia
activities• Sequester equipment• Contact the hospital Risk Manager immediately • Anesthesiologist and other individuals document relevant
information • After discussion with the incident supervisor, write on medical record
relevant information about what happened and actions taken• Complete and file incident report as soon as practical• State only facts. Do not use judgmental terms • Consult early and frequently with the surgeon.• Immediately call other consultants who may help improve long term
care
• Primary anesthetist concentrates on continuing patient care.• Notify a physician responsible for supervision of anesthesia
activities• Sequester equipment• Contact the hospital Risk Manager immediately • Anesthesiologist and other individuals document relevant
information • After discussion with the incident supervisor, write on medical record
relevant information about what happened and actions taken• Complete and file incident report as soon as practical• State only facts. Do not use judgmental terms • Consult early and frequently with the surgeon.• Immediately call other consultants who may help improve long term
care
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SummarySummary
Simulate Avoid Fixation
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