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EDITORIAL Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 2  |  Page : 87-88
Errors in cardiac anesthesia - A deterrent to patient safety


Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bannerghatta Road, Bangalore - 560 076, India

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Date of Web Publication3-May-2010
 

How to cite this article:
Chakravarthy M. Errors in cardiac anesthesia - A deterrent to patient safety. Ann Card Anaesth 2010;13:87-8

How to cite this URL:
Chakravarthy M. Errors in cardiac anesthesia - A deterrent to patient safety. Ann Card Anaesth [serial online] 2010 [cited 2020 Apr 7];13:87-8. Available from: http://www.annals.in/text.asp?2010/13/2/87/62925


Although most surgeries cannot be undertaken without anesthesia, the risks associated with anesthesia must be dialed down to a minimum, as anesthesia, unlike surgery, has no therapeutic value. [1] Errors in anesthesia are known to occur with unpleasant outcomes. In otherwise healthy patients (American Society of Anesthesiologists Grade 1 patients), the risk of anesthesia-linked deaths is approximately one in every 250,000 patients. [2]

The analysis of closed claims in anesthesia by Gild showed that the incidence of equipment-related errors in cardiac anesthesia were higher in comparison to the non-cardiac group (37 versus 9%, P < 0.01). [3] Conversely, the same study shows that respiratory-related damaging events were responsible for only 9% of the adverse outcomes in the cardiac group, in contrast to 32% in the non-cardiac claims (P = < 0.01). The study also concluded that, despite the shortcomings of a closed claim analysis, it was reasonable to infer that the care of intravenous catheters and cardiopulmonary bypass equipments may reduce the overall incidence of such errors in cardiac anesthesia. Pundits in the field of clinical statistics may dismiss this data with an explanation that more equipment is used in cardiac anesthesia as compared to non-cardiac anesthesia, thus causing more errors. In these days of Six Sigma certification, such an explanation may not hold much water. The Six Sigma certification seeks to improve the quality of the process outputs by identifying and removing the causes of the defects and minimizing the variations in manufacturing and business processes. [2] It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ('Black Belts', 'Green Belts', etc.) who are experts in these methods. By this standard, healthcare providers will soon be termed 'vendors' and the patients, the 'clients'. It is but natural that we, the 'vendors', are expected to ensure that the 'service' is free from errors - as is the practice in other industries.

Kohn and his colleagues' report, 'To Err is Human,' attempted to highlight the seriousness of this often preventable issue. [4] Serious efforts of key players, such as, anesthesiologists, hospital administrators, various related associations (such as the Society of Cardiovascular Anesthesia (SCA) and the Society for Healthcare Epidemiology of America), and organizations like the World Health Organization, towards eliminating this problem has caused little impact. We might be unaware of these efforts, as the incidences of erroneous surgeries on patients, anesthetic mishaps due to equipment malfunction, and other avoidable complications, have gone unreported in many cases. [5] Despite there being a national policy in the United States of America to prevent wrong-site surgery, there is little or no data showing the effectiveness of the scheme. The SCA took upon itself the responsibility of achieving the goal of attaining harm-free cardiac surgery through an initiative called the Flawless Operative Cardiovascular Unified Systems (FOCUS).

Towards realizing this aim, Martinez and colleagues published their study involving a continuing collaboration between a research team at the Johns Hopkins University Quality and Safety Research Group and the SCA Foundation, to achieve harm-free cardiac surgery. [5] This study apparently differs from their earlier works - "Prior efforts to improve patient safety have been independent rather than interdependent, competitive rather than cooperative, and focused on efforts rather than results". Previously, few research projects had integrated diverse disciplines to develop a more comprehensive view on patient safety. The Locating Errors Through Networked Surveillance (LENS) project which is an initiative of the SCAs, FOCUS described by Martinez et al., sought to overcome this very limitation of diversity of disciplines involved and comprehensiveness of the issue. They involved various disciplines such as organizational sociology, human factors engineering, and clinical medicine to develop tools to evaluate safety risks. Their project was also structured around identifying hazards, prioritizing hazards, and developing risk-reduction interventions. The SCA is now in the early stages of prioritizing hazards based on their estimated frequency, severity of harm, likelihood of detectability, and preventability. Once the prioritization is completed, the SCA Foundation will convene relevant clinical and paraclinical personnel to further identify the hazards, and the tools to reduce these risks will be studied at a multi-centric level. This move by the SCA is indeed laudable. It is imperative that the Indian Association of Cardiovascular and Thoracic Anesthetists join hands with the SCA and participate to set benchmarks in safety measures in cardiac surgical practice. A journey in that direction is best begun now.

It is vital to address safety issues in cardiac surgery and anesthesia. The ultimate goal of cardiac surgery is not only to correct the existing cardiac problem, but also to assure a long and good quality of life to the patient, which, in my opinion, will emerge from the flawless execution of the surgery (and the anesthetic) by the personnel involved. All deterrents coming in the way of such a target should be identified and systematically eliminated. Any compromise in safety will make the entire faculty of cardiac surgery and anesthesia vulnerable.

 
   References Top

1.Botney R. Improving patient safety in anesthesia: a success story? Int J Radiat Oncol Biol Phys 2008;71:S182-6.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Fasting S. Risk in anaesthesia. Tidsskr Nor Laegeforen 2010;130:498-502.  Back to cited text no. 2  [PUBMED]    
3.Gild WM. Risk management in cardiac anesthesia: the ASA Closed Claims Project perspective. J Cardiothorac Vasc Anesth 1994;8:3-6.  Back to cited text no. 3  [PUBMED]    
4.Kohn L, Corrigan J, Donaldson M, editors. To err is human: building a safer health system. Report from the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 1999.  Back to cited text no. 4      
5.Martinez EA, Marsteller JA, Thompson DA, Gurses AP, Goeschel CA, Lubomski LH, et al. The Society of Cardiovascular Anesthesiologists' FOCUS initiative: Locating Errors through Networked Surveillance (LENS) project vision. Anesth Analg 2010;110:307-11.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Murali Chakravarthy
Department of Anesthesia, Critical Care and Pain Relief, fortis hospitals, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.62925

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This article has been cited by
1 Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning
Mohammad Hamid,Mohammad Irfan Akhtar,Fauzia Nasim Minai,Amar Lal Gangwani
Open Journal of Anesthesiology. 2013; 03(09): 408
[Pubmed] | [DOI]



 

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