Patient Safety

12 Patient Safety Thoughts for 2012

Dr Robert Stoelting (President, Anesthesia Patient Safety Foundation) on postoperative patient safety risk:

Clinically significant drug-induced respiratory depression (oxygenation and/or ventilation) in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Dr. Frank Overdyk (Professor of Anesthesiology and Perioperative Medicine at the Medical University of South Carolina) on the need for zero tolerance:

Serious postoperative adverse events such as deaths and anoxic brain injuries due to opioid acute pain management are a significant and preventable threat to patients, for which all institutions and healthcare providers must have zero tolerance.

Dr. Melissa Langhan (Assistant Professor of Pediatrics, Emergency Medicine, Yale School of Medicine) on how to enhance patient safety:

Unfortunately, continuous capnography is not routinely used outside of the operating room. Capnography can really enhance patient safety, and healthcare professionals need to think about using it more often

Dr. Daniel Sessler (Professor and Chair of the Department of Outcomes Research at the Cleveland Clinic; Director, Outcomes Research Consortium) on the need for continuous monitoring:

Continuous respiratory monitoring, including the use of both capnography and pulse oximetry, is essential for the safe administration of patient-controlled analgesics. A patient experiencing respiratory depression, if undetected, can easily progress to respiratory arrest and consequent brain damage or death.

Dr. Marc Popovich (Medical Director, Surgical Intensive Care Unit, Cleveland Clinic) on the 10% surveyed who disagreed on the need for continuous electronic monitoring:

I am quite shocked that the disagree group is that high! The question asked whether continuous monitoring should be ‘available and considered’ for all patients. What this survey result is saying is that 10% do not have monitoring available and it is not even being considered for their patients after surgery.”

Rob Hutchison (Associate Professor, Department of Pharmacy Practice, Texas A&M Health Science Center) on respiratory depression:

Respiratory depression occurs more often than most clinicians think with PCA.

Dr. David Crippen (Associate Professor of Critical Care Medicine, University of Pittsburgh Medical Center) on the need for real time monitoring of adequacy of ventilation:

To prevent respiratory depression, patients need to be monitored in real time, and not just when caregivers periodically check on their patients. Capnography is the only way to assess adequacy of ventilation (not oxygenation) for patients on controlled mechanical ventilation.

Dr. Jenifer Lightdale (Director, Patient Safety and Quality, Division of GI/Nutrition, Children’s Hospital Boston) on current guidelines:

Current guidelines for monitoring patient safety during moderate sedation in children call for continuous pulse oximetry and visual assessment. Pulse oximetry does not measure ventilation.

Dr Richard Dutton (Executive Director, Anesthesia Quality Institute) on the number of errors involving patient-controlled analgesia (PCA):

PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.

Dr. Elliot Krane (Director, Pediatric Pain Management, at Lucile Packard Children’s Hospital, Stanford) on when errors may occur:

When there is a handoff of a patient from team to team, or location to location (such as OR to PACU, OR to ICU, ICU to OR, etc.), I have been impressed that there are times in which things fall through the cracks, from relatively minor things like missed doses of antibiotics, to critical things like ventilators not being properly connected, potentially resulting in hypoxia.

Dr. Brendan Carvalho (Associate Professor, Department of Anesthesia, Stanford University) on the need for a safety checklist:

While the APSF recommendations are important, they are part of a bigger picture of improving care of these patients. The checklist would be to remind clinician’s of some of the recommendations that should be considered. The checklist should not be telling clinician’s to blindly follow recommendations that may or may not be necessary or work. The checklist would many other aspects (as outlined in the next question) that are not specifically covered by the APSF.

Dr. Andrew Kofke (Co-Director, Hospital of the University of Pennsylvania Neurocritical Care Program) on finding patients “dead in bed”:

We should stop the found dead in bed syndrome. The use of a well-constructed checklist that ensures proper procedures are followed in patient-controlled analgesia would enhance patient safety.

Dr Philip Lumb (Chair of Anesthesiology, Keck School of Medicine at the University of Southern California) on the need for continuing education:

Continuing education should be provided for all individuals taking care of patients who have received procedural anesthesia/sedation. Special emphasis should be given to ‘non-traditional’ areas outside the purview of normal operating room and perioperative procedures and surveillance.  This is increasingly important for office-based practices, interventional suites (GI, Radiology, etc) and ambulatory surgery centers.

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