June FY20

[kristenhorsman]

The June journal article was submitted by Belinda Gardner. She chose the AANA article “Preventable Closed Claims in the AANA Foundation Closed Malpractice Claims Database.

You can find the link here.

Please answer the following 2 questions:

1. After reviewing the claims, do you believe that the CRNA in the cases presented could have prevented the adverse outcomes? Why or why not?



2. Can you think of any instances where these adverse outcomes could occur within your/our practice, or where a change in practice may reduce the risk of adverse outcomes? Do you think you will change your practice after reading this article?

[Kelly Rechtin]

1. Most of these adverse outcomes could have been prevented. In the case where the patient presented for elective surgery with chest pain, and they gave Morphine and nitroglycerine, they should have canceled the case - but instead they proceeded and the patient died 3 hours after surgery. In the case where the equipment was known to be faulty before the case, and the patient experienced an anoxic brain injury as a result of inability to verify the ETT was in the right place, they should have had functional equipment before the case started.

2. There is always the potential for complications, and there were several cases that I could see occurring within our practice. One - a mac case with a morbidly obese patient - the patient became apneic after induction drugs given and the CRNA was not able to mask ventilate or intubate. Another, due to production pressure, the CRNA was pressured by the surgeon and went against their better judgement, and the patient ended up dying due to an inability to secure the airway.

It is always helpful to review these cases, as we do with PBLD, so we can learn from others. It makes us more aware of the potential for complications, and helps us have more foresight before proceeding with a case in which we may have questions about whether or not to proceed.

[Vania Milnes]

1. I think that most could have been prevented. Lack of proper/appropriately functional monitoring equipment and poor decisions like ignoring obvious cardiac issues/EKG abnormalities seem pretty straightforward. But in the situation where an attending neglects to inform the CRNA of a CRITICAL piece of information like pulmonary HTN is more questionable. When working in a team setting like that, I'd like to think that I can trust the attending to communicate important info that they discover during a preop. Otherwise I'd feel like I had to RE-interview every patient personally, which doesn't make sense. How is that the fault of the CRNA?

2. Certainly production pressure, lack of communication and faulty equipment are real issues here at Hopkins. Being such a large hospital with so many OR's makes it difficult sometimes to be completely familiar with an area, practices, attendings, equipment, other CRNA's and nursing staff, and even procedures and patient populations. This unfamiliarity and lack of comfort can certainly lead to mistakes and errors in judgement. It's important to take the extra time to assure comfort with all aspects of care. It reminds me to take my time, no matter what anyone else is saying or doing! Vigilance is key even under duress.

[Dahila Rouchon]

Thank you so very much for this informative and vital reminder on the importance of vigilance in our practice. It's what makes the difference in anesthesia providers. Truly, I hope anesthesia programs are teaching these important lessons and how to manage a lawsuit as well if ever presented in our practice. My program did not, and neither did it with other providers I spoke with. To answer your questions,
1. Yes, the CRNAs could have prevented the adverse outcomes by doing a thorough physical assessment themselves to include reading CT scans, comparing 2 previous EKGs, knowing what the PA/RVSP pressure is for all patients, probing patients for a thorough history and preforming a detailed physical exam with great emphasis on airway, heart, lungs, LE edema and skin turgor. CRNAs must keep communication with surgeons beginning in preop to ask, "what specifically do you need for this case?" Ascertaining bovie use is commonplace for head/neck cases and informing the surgeon you will turn off O2 during use therefore to inform you when employed is standard of care. Failure to disclose history by the patient is not uncommon as they can be poor historians, do not want a case to be cancelled and thereby not disclose new onset chest pain or SOB. Being specific about exercise tolerance is helpful and when unable to do so due to immobility, there should be a low threshold to inquire about an echo for procedures that require GA. Regarding obesity and MAC, this is a slippery slope. Cases where MAC is needed GA will be used instead if there's obesity with OSA, COPD and any other risk factor to increase hypoxia when sedation begins. Even for outpatient hysteroscopies/EGDs etc., I would utilize GETA vs. LMA or sedation to ensure adequate ventilation with limiting preop benzodiazepines and narcotics. Choosing GETA over LMA for high RVSP should be standard and keeping a large gradient of the SBP over the RSVP is critical.CRNAs cannot depend nor assume another provider performed a thorough preoperative assessment. We practice under our own license and will be held accountable to have known all knowledge regarding the case no matter in what point of the case we assume it. A detailed description for example of tooth # 9 or # 29 whether it is chipped or loose can prevent litigation for repair, in the event it comes out of a claim that it was chipped under anesthesia's care.
2. All the above can occur with lack of vigilance, lack of communication, lack of assuming responsibility.
3. Regarding my own practice with ocular cases, a similar situation occurred to me and for this specifically I would definitely reinforce to the surgeon to notify me when a very stimulating part of the procedure is to occur. We frequently do either MAC of GA/LMA for eye procedures. In the instance where the anesthetic is adequate, fluid replacement has occurred (but no foley is present, no 3rd spacing), appropriate narcotics are on board, but the patient is not paralyzed, a patient can move if the surgeon did not do a retrobulbar block or it was insufficient by the trainee. If anesthesia is not forwarned as we typically are in other procedures ("we're about to get into bleeding, cross clamping a major vessel coming, we are going to debulk the vascular part of this tumor etc.) the patient could cough in this case retinal detachment. An astute surgeon will tell anesthesia. Similarly the anesthesia provider needs to tell the surgeon, please let me know when you will give added stimulation and don't assume the block is sufficient. Reinforcing this habit I will do and it's all a good reminder of how important vigilance must be in all cases in our care.

[Jocelyn Datud]

Very interesting article.

A lot of the cases are preventable. The cases presented can actually happen to any of us, hence it is a good reminder of the important points that we should be always aware. But there are also some instances that no matter how vigilant and cautious we are, something can still happen to our patients. Preparing for the worst is always a good practice. Maintaining an open communication with the other anesthesia team, the surgeon, and the nurses in the room is very important. During difficult cases, it is helpful to huddle with the other members of the surgical team before proceeding with the case (which can be done during time-out.) One more important thing that we should do is building a good relationship with the patient which is quite challenging since we just meet the patient for few minutes before the surgery.

This is definitely a very eye-opening article.

[Jackie Howell]

1. I believe these adverse outcomes could have been prevented. It is very straightforward to cancel a patient with ongoing chest pain that presents for an elective surgery. I do believe that in the care team model approach, pertinent information obtained in the history and physical exam should be shared with both team members (MDA and CRNA).


2. These unfortunate events could happen to any of us. The things we can control have already been mentioned: vigilance & communication. Reading articles such as these highlights the importance of best practice standards and upholding those standards in our delivery of care.

[Amy Swank]

Excellent review of Closed Claims - always so interesting.

1.  Yes, unfortunately, the CRNAs could have prevented some of these outcomes as validated by the data, which shows 50% could have been prevented.  Performance pressure, and miscommunication definitely are major contributors in these events and in our everyday lives here.  

2.  I could see some of these event occurring within our facility as well.  We have people involved and the the flaws that accompany them.  Add on the number of personnel involved in each case in an academic setting and the opportunity to drop a link in the chain as well as the common use of cut and pasting previous H and P's and there are real recipes for problems.

Always a good reminder to maintain high standards of care and be ever vigilant.  Love that slogan we have around here: "be ready to you don't have to get ready" 

[Robin Boynton]

1. Yes, I do think that many of the presented cases could have been avoided. A thorough pre op assessment with awareness of all medical conditions, medications being taken and Pertinent labs and tests are needed for the situational awareness that was discussed in the article. Of the cases discussed, the patient with chest pain and ekg changes could have been prevented by cancelling the procedure and obtaining a cardiac consult.


2. These adverse outcomes are apt to happen anywhere but may be especially prevalent in areas with high volume turnover and pressure for quick assessments, lack of communication, and pressure to proceed with cases without thorough evaluations. Vigilance is of the utmost Importance in our practice.at all times. Very good article.

[kels]

1.) I do believe that the CRNAs in most of the cases presented could have prevented the adverse outcomes. However, I would have liked to learn more info about the pulm HTN case. In most of the cases presented the CRNA fell into one or more of the following problematic areas, communication failure, violation of standards and errors in judgement . For example, any elective case where the pt c/o chest pain should at the very least be delayed for cardiac work up and clearance and or cancelled.

2.) Years ago I worked at a hospital that did a team huddle in preop . I always thought that this was a great idea because the entire team was together discussing the case with the pt nearby. I enjoyed discussing the case before the pt even made it into the room in case the pre op rn had any concerns . All pertinent info about the pt and details of the surgery was talked about . Everyone always seems to enjoy this huddle and never rushed it to make sure we were all on the same page. Communicating and making sure everyone is on the same page helps to prevent some errors from occurring .

[emedina1]

Yes, I believe that some of this cases could have been prevented by really paying attention to the pre-op done by the attending . I must say I have to go over the pre-op done by some attendings whom i know do not really do a very thorough job. In the case where the
patient had some critical medical issues maybe cancelling the case would have been a good idea.

I believe a discussion with the people involved before the case would have helped prevent a sentinel . Knowledge of the standard of care and really adhering to it ,is a good practice might not prevent a negative outcome at times it is not within our scope.

[aileenm4]

these things are always good to discuss
1. I do also believe that situations could have been avoided,hindsight is always 20/20 and we never know the entire details of the situation
however, one of the issues that sticks out in my mind was not checking the patient and assuming that the monitor was faulty. this is a basic that we as preceptors teach our SRNAs
2. as above, communication is key with the anesthesia team members and surgical colleagues. having trusted rapport is best for patient care

[angie brooks]

1. After reviewing the claims, do you believe that the CRNA in the cases presented could have prevented the adverse outcomes? Why or why not?

As the article stated, it appears that most of the cases that had adverse outcomes could have been prevented. Lack of communication with other anesthesia providers, surgeons, nurses, or patients can lead to a lack of knowledge or understanding of the situation. Deviation from standards of practice whether because we are being rushed, or have become accustomed, etc can lead to many issues. We need to make sure that our patient care plans are based on the patient in front of us and not on what the pressures of the surgeon or administration. If equipment and monitors are faulty than our biggest standard of care is not being met. There is no way that we can properly care for a patient. If it is determined that the monitors are faulty after the procedure has started evaluation of the patient is always the backup until new monitors can be put into place. We have no excuse when this standard is not followed. There are times when we can make errors in judgment when we are tired or overworked. We need to be diligent with ourselves, making sure that we are at our best for our patient. Sometimes that means asking for a break, declining a shift, or having to take the day off if we are sick.


2. Can you think of any instances where these adverse outcomes could occur within your/our practice, or where a change in practice may reduce the risk of adverse outcomes? Do you think you will change your practice after reading this article?

Any of these cases can happen to all providers who deliver anesthesia. As the article stated vigilance is the key. We must make sure that we are always aware of our patients and not becoming complacent. This article was a very good reminder that very bad outcomes can happen to our patients if we are not always on our toes making sure that everything is as it should be. Bad outcomes can happen to our patients even if we make sure that everything is in place. But we will be more prepared and ready when this does take place if we remain vigilant.