Most adverse events are not caused exclusively by a single individual or due solely to the patient's particular disease processes. The situation that arises is more likely to be one in which there has been an adverse event or a poor outcome that involves multiple caregivers and may or may not involve negligence. Patients and families (as well as the caregivers involved) may experience stress not just around the event or outcome itself, but see it increased by subsequent communications and interactions that are not handled well or do not meet their needs at the point in time.
In the Organized Response to Major Anesthesia Accident Will Help Limit Damage: Update of Adverse Event Protocol Provides Valuable Plan the detailed protocal runs through verification, consultation, communication and shutting down of the OR (by not turning off, cleaning or fixing anything).
Three personal stories shared with the APSF Board of Directors highlight the importance of getting patient safety responses correct as “Incredible Save”, “A Parent’s Nightmare” and “A Question of Competence” offer differing cautionary tales. The many general and specific lessons drawn by event participants is undiminished over 5 years, can be generalized to other disciplines and would be a worthy challenge for any hospital in 2010.
One important item that could immediately and directly help prevent or mitigate patient injuries was again broadcasting a reminder that “Administrative Guidelines for Response to an Adverse Anesthesia Event” have been published and are available on the APSF website: www.apsf.org, “Resource Center,” “Clinical Safety Tools,” then “Adverse Events Protocol.” Another suggestion was the simple idea of surveying patients/families to help determine what type and how much information and communication they really want, both in general and specifically concerning an adverse medical event....A primary specific initiative is to continue to collect (possibly including through a “hotline” to the APSF) and publicize these potent “stories” of patients/families who have experienced an adverse anesthesia event. ... A related initiative will be the use of the great power of the telling of these stories to develop a curriculum in “the patient side of anesthesia patient safety” for distribution to all anesthesiology residency and nurse anesthesia training programs, as well as to medical schools for incorporation into their clinical teaching. Closely tied would be additions to modules used in anesthesia simulator training that add experience in post-event management of both the patient/family and the involved anesthesia provider. This intense role-playing likely would evoke strong emotions and would be videotaped for the debriefing of the participants in the specific simulation and also for potential inclusion in curriculum modules for anesthesia trainees and medical students. Having these modules available on the web for all anesthesia providers through their respective national professional organizations also would have a significant impact because their direct relevance and inherent drama would provoke widespread interest and attention.
One major recurrent theme was the failure of communication with the patient/family at the time of the catastrophic event and thereafter. The overall concept of trying to shift from a “culture of blame” to a “culture of learning” certainly applies. It was agreed that, in the spirit of “the patient’s bill of rights,” there should be an expectation by the patient/family of open communication and full disclosure (even to the point that the surgical/anesthesia consent forms should specify that after any event, prompt full disclosure will be made). The expected concerns about risk management and the potential legal liability implications of apologies and full disclosure were expressed, but reference was then made to the study from the VA system demonstrating a significant reduction in liability costs associated with prompt full disclosure after an event. Related was the favorably-received suggestion that patient care facilities where anesthetics are administered should have an ombudsman or “patient advocate” always immediately available or on call so that this advocate can immediately interpret, facilitate communications, and organize support of all types for the involved patient/family in the event of an anesthesia accident, or any acute medical adverse event for that matter. This tied in to the projected goal that perioperative services should be “high-empathy organizations” as well as high-reliability organizations. The proposal that patient/family representatives be included on the committee for the peer-review analysis after an adverse event provoked significant discussion, but did not yield a consensus. However, the suggestion that the institution and the practice group involved with an anesthesia accident share with the affected patient/family the details of changes made following the event (whether policy, procedure, behavior, equipment, or organizational) intended to prevent any recurrence of that type of accident met with widespread approval.
Promoting thoughtful, compassionate, and open support for anesthesia providers who have been involved in a catastrophic anesthesia accident (even one with an eventual good outcome) is another unanimously accepted proposal resulting from the APSF Board workshop. Clearly the front line and the bulk of this effort should be at the local level, within the institution and immediate group of the involved anesthesia provider(s). Prospective concrete plans that are widely disseminated to all involved should be in place in order to avoid a confusing scramble of disparate resources at the time of an event. Group leaders and facility administrators should immediately activate the pre-planned response to provide support and counseling, as well as specific advice and encouragement about disclosure to the involved anesthesia personnel. Further, it was suggested that the APSF could establish another type of “hotline” to offer situation-specific suggestions to assist and support the personal needs and concerns of anesthesia providers finding themselves under stress following involvement in an adverse event. The more general question of anesthesia providers under so much personal stress as to be dangerously distracted and a safety risk was also broached. Enhanced vigilance and sympathetic support from coworkers, promoted by articles such as this one, was seen as the best immediate strategy.