PATIENT SAFETY REPORT€¦ · possible or desired, please at least consider eating break-fast and lunch during a working day. Omitting a meal to lose weight should be discouraged

PATIENT SAFETY

TOWARD EXCELLENCE IN HEALTHCARE

REPORTQUARTERLY PERIOPERATIVE INCIDENTS REPORT

Newsletter #014 - january 2020

Patient Safety Report

Mail : [email protected] / [email protected] // Site : anesthesiasafetynetwork.com 2

INTRODUCTIONNewsletter #014 - january 2020


Happy New Year to all of you! This new decade should give us the opportunity to highlight and develop the full potential of the Human being not only as an individual but also as a member of a team, in order to improve the quality and safety of care. Indeed, the provider is the one who carries medical innovation to the patient’s bedside. Without him or her, no progress can be made to achieve the process started in the research and development departments to ensure high reliable healthcare.The ASN journey has begun its 4th year of existence and we’ve decided to change our name to address all healthcare professionals in medical, surgical and obstetrical institutions. It is indeed critical to share information with each other in order to better understand each other’s concerns and thus enhance collaboration among the different stakeholders.For the first time, the editorial has been written by surgeon Peter Brennan and one of his radiologist colleagues Rachel Oeppen. It raises awareness of the impact of physiological needs on cognitive performance.In this issue, we also focus on the work space ergonomy in operating theatres by joining the vision of the reporter with the views of Stéphane Kirche and Alexandre Benoist (biomedical and CRNA engineers) and Guillaume Tirtiaux (airline pilot).As you will discover, the updating or the writing of procedures or protocols are frequently proposed as the main points of improvement in some cases in this newsletter. This was also the subject of our intervention at the WEARE 2019 congress: Take action by writing the procedures, share them and train yourself to use them! These are the cornerstones for successful implementation!

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Mail : [email protected] / [email protected] // Site : anesthesiasafetynetwork.com

Since the new declaration platform was set up, we have been very im-pressed by the fact that the quality and quantity of the declarations have increased. The possibility of sending photos is also an added bo-nus that enriches the declarations. Furthermore, the natural evolution of the incident analyse is shifting from reports on equipment to reports on our “ Own At-Risk Behaviour ”. That’s clearly for us a proof of « maturity ».

Finally, after the success of the first SafeTeam Academy training mo-dule focused on teamwork and the surgical checklist, we will carry on the production of 4 new modules by the end of June 2020.

We hope you will enjoy this issue. Thank you in advance for sharing with us your feedback on this newsletter and also on the new incident reporting system.

François Jaulin and Frédéric Martin


“SHARING TOGETHER FOR A BETTER UNDERSTANDING OF EACH OTHER’S

CONCERNS”

Anesthesia Safety Network




EDITORIALOPTIMISE OURSELVES AT WORK TO PROVIDE THE BEST CARE FOR PATIENTS

Peter Brennan is a Consultant Surgeon with an interest in head and neck cancer and reconstruction, working in Portsmouth, UK. He has a personal chair in Surgery in recognition of his extensive research and education profile. To date he has published over 580 papers including more than 60 on human factors and patient safety. He is editor of 5 major surgical textbooks including the forthcoming and much anticipated Gray’s Surgical Anatomy (due to be published in

November 2019) which begins with a chapter on minimising error in the operating theatre.Peter is recent past Chairman of the MRCS Committee (the exam required to enter higher specialty training in surgery in the UK and Ireland) and is the current research lead for MRCS, driving up quality assurance for this important examination.His extensive HF work, collaborating with airline pilots, National Air Traffic Services (NATS) and more recently the Red Arrows, has resulted in many changes to theatre practice, better team working, reducing hierarchy and improvements in patient safety across medical specialties, as well as changing the MRCS delivery nationally. Peter has recently been awarded a PhD entitled ‘Applying HF to Improve Patient Safety’ – likely to be the first of its kind in healthcare. His profile and reputation as an engaging and entertaining speaker and trainer leads to many invites from local to international level, and he works with national organisations including the Royal Colleges and GMC In helping to reduce medical error.

1) Peter A Brennan MD FRCS (Eng), FRCSI, Hon FRCS (Glasg), FFST RCS (Ed)Consultant Maxillofacial Surgeon, Honorary Professor of SurgeryQueen Alexandra Hospital, Portsmouth PO6 3LY, UK

2) Dr Rachel S Oeppen FRCR, MRCP (UK) Consultant Radiologist, University Hospital Southampton, Southampton, SO16 6YD UK

Correspondance to Professor Peter A Brennan : [email protected] +44 2392 286736 Fax +44 2392 286089 @BrennanSurgeon



INTRODUCTIONAs doctors, we sometimes don’t look after ourselves at

work, forgetting to take regular breaks, drinking inade-

quate quantities of fluid, or missing lunch while caring for

patients. Anaesthesia and surgery are demanding profes-

sions with theatre days often starting early and finishing

late. Sometimes there are seemingly few opportunities for

breaks unless we ensure these occur. A critical component

of being ‘optimised’ at all times to reduce the chance of pa-

tient harm and human error is to take those regular breaks

and eat and drink regularly

Many staff have prolonged periods without food and drink

even before starting work if not regularly eating breakfast.

With limited opportunity for catching up on nutrition and

hydration during the working day, some colleagues may be

under hydrated or adequately fed to optimise their own en-

ergy, concentration and performance.

There are relatively few healthcare publications about the

importance of nutrition and hydration to optimise perfor-

mance. Many of our own human factors promotion ori-

ginates from aviation, where safety and optimisation are

taken seriously. (1)

HYDRATION AT WORKWater accounts for over 60% body mass. In healthy and

active people, water balance is regulated to within 0.66%

of bodyweight (2). Even small deficits impede physical per-

formance and worsening dehydration causing headache,

sleepiness, impatience and apathy (3). How many come

home with a headache because of a lack of fluid drunk du-

ring the day?

While thirst cues usually present before the ill effects of

low hydration occur, it is easy see how staff might become

under hydrated if they fail to look after themselves. The im-

portance of hydration for pilots is well known as significant

reductions in flight performance and spatial cognition occur with

dehydration equivalent to a 1 to 3 kg loss of body mass (4).

We advocate drinking regularly and stopping for short

breaks every 2-3 hours. Individual requirements vary

considerably, but as a minimum, 2L of fluid per day is

recommended unless restriction is needed on medical

grounds. Caffeine- containing drinks including tea and cof-

fee have a diuretic effect but this does not offset the fluid

they provide.

Healthcare professionals might not be aware how low hy-

dration affects performance or stop to think why their urine

is so concentrated. Theatre teams could agree to have re-

gular fluid breaks when planning all day operating lists.

Fluid should be palatable and available in different forms,

e.g. water, canned drinks cordials, and ideally drunk regu-

larly throughout the day.

NUTRITIONIn aviation, hunger can lead to including poor communi-

cation between flight crew and other performance-related

errors (5). Pilots who miss breakfast report a 22% increase

in cognitive dysfunction (5). Children’s learning and acade-

mic performance is affected when they do not eat break-

fast regularly (6). Missing breakfast leads to a reduction in

metabolic rate with fewer burned calories, lower energy and

motivation. We strongly recommend having something to

eat before starting the day.

Since eating breakfast has a positive effect and nutrients

deplete and need replacing throughout the day, anaesthe-

tists and surgeons should not only be eating before work,

but also during the day. A break also helps with subsequent

concentration and the completion of clinical tasks. While

eating as often as drinking is probably not essential, eating

a balanced portion of carbohydrate, fat and protein every

3-4 hours is beneficial, though as frequency is increased

its size should be smaller than a standard meal. If this is not

possible or desired, please at least consider eating break-

fast and lunch during a working day.

Omitting a meal to lose weight should be discouraged as

overall hunger is increased resulting in over eating at the

next meal. Fast/processed food is linked to poorer perfor-

mance (7). High carbohydrate chocolate bars do not satisfy

hunger, but raise insulin levels and can paradoxically reduce

performance.

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To give our patients the best care possible and to reduce

the chance of medical error, we must make sure we look

after ourselves too. This vital pre-requisite to safe medi-

cal practice is supported and actively encouraged by many

senior healthcare leaders.

Figure 1- Urine (pee) colour chart. Dilute urine confirms

that we are well hydrated.

Bibliography

1. Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition of human fac-tors and how to minimise error. Br J Oral Maxillofac Surg. 2016; 54:3-7.

2. Cheuvront SN, Carter R, Montain SJ, Sawka MN. Daily body mass variability and stability in active men undergoing exercise / heat stress. Int J Sport Nutr Exerc Metab. 2004; 14:532-540.

3. Adolf EF. Physiology of man in the desert. 1947, 1st Ed. New York Inter Science Publishers

4. Lindseth PD, Petros GN, Jensen TV, et al Effects of hydration on cognitive function on pilots. Mil Med; 2013; 178:793-98.

5. Bischoff J, Barshi I. Flying on empty: ASRS reports on the effects of hunger on pilot performance. Proc Internat Symp Aviation Psychol. Dayton, Ohio 2003: 125-29

6. Adolphus K, Lawton CL, Dye L. The effects of breakfast on behaviour and academic performance in children and ado-lescents Hum Neurosci, 2013: 7: 425.

7. Florence MD, Asbridge M, Veugelers PJ. Diet quality and academic performance. J School Health. 2008: 78, 209-15.

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How to be more successful every day at work

For a long time, the investigation of sentinel events has been based on «finding the gap». This approach has some major weaknesses: it is spontaneously blameworthy and therefore badly received: « the good professional follows the rules ». Looking at the gap does not mean understanding its root causes. Sweeping the skeleton under the carpet is a direct consequence of this approach.A very sensitive methodological progress consists of considering the gap as a symptom of dysfunction whatever its nature. That’s This is why the Organisational and Human Factors (OHF) is so interesting in proposing knowledge to «trace» the symptom back to its systemic origins. In this way, the analysis become deeper and more powerful.However this approach remains organized around the gaps, even if their reading is radically different. Nevertheless, it’s positive and focused on strengthening the conditions for achieving success.Its principle can be simply stated: “any organisation, any collective, develops strategies and practices that ensure high performance in patient safety”.If there is an incident or a near-miss that indicates that these strategies and practices are not as effective as hoped for.It’s therefore our responsibility to strengthen the conditions for their success. There are several steps to do this : • Identify the goal of the approach that did not work• The problem(s) encountered• Establish the conditions for success in order to achieve this objective by avoiding these problems• Addressing issues related to improving the conditions for success

There is some discussion about a C-section room to be reorganized to accommodate a certification inspection.• Goal of the activity: adaptation of the facility for patient safety and the fulfillment of established patient safety performance criteria.• Problems encountered : Full compliance before a certification inspection, adaptation of the environment without any consultation between users.• Conditions for the success of the « upgrading » process and the adaptation of the installations : Interactions and anticipations between certification actors• Dealing with problems: a « no modification of facilities without consulting stakeholders » provision

Or, how to do better next time to avoid mistrust, resentment, irritation and decreased the patient safety ?

You can try these 4 steps on the other cases : Goal of the activity, Problems encountered, Conditions for success, Problem handling.And, if this enlightens you, continue for you.It’s up to you...

Claude VALOT Former researcher at the Institut de Recherche Biomédicale des Armées in Brétigny sur Orge and senior human factors consultant at DEDALE.

«EVERY ORGANISATION, EVERY TEAM, DEVELOPS STRATEGIES AND PRACTICES THAT ENSURE PERFORMANCE

IN PATIENT SAFETY.»




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THE ANCHOR TRAPS. WHEN ONE PROBLEM CAN HIDE ANOTHER !I was the on-call anaesthetist who ended the program and ensured continuity of care in the PACU on a Friday night after a busy week.An ASA IV patient with an implantable defibrillator (ID) for dilated heart disease had been admitted into the PACU after a traumatic hip surgery. There wasn’t a cardiologist in our hospital. We tried to transfer this patient to another hospital with a cardiologist intensive care unit. The patient was hospitalised for 3 days and was bedridden with differing opinions on the management of his implantable defibrillator. After numerous unsuccessful attempts to transfer him, we decided to proceed with the surgery. He was operated on without any incident. The highly skilled anesthesiologist who was in charge of him had reviewed the guidelines and was ready to deal with any malfunction of his ID. The patient was extubated in PACU. My colleague explained to me that the patient case before he left the hospital. I went back to the OR to take care of a woman. Tem minutes later I was called to help the PACU nurse. When I arrived at the PACU the « famous » patient seemed to be choking and in a coma. His face was cyanotic but he was reacting to painful stimuli. His blood pressure was 50/35 and had no pulsoxymetric signal. The EKG revealed that he had a sinusal tachycardia. We immediately put on a high concentration oxygen mask on his face and looked at his vital signs. My colleague arrived with a magnet in his hand and applied it on the ID. He yelled that it was due to the ID. I didn’t agree with the suspected diagnosis. I asked the nurse to prepare norepinephrine and to inject crystalloids quickly. The bad situation was reversed in five minutes that seemed endless after several bolus of 10 microg IVD of norepinephrine and infusion of noradrenaline 0.75 mg/h. The suspected diagnosis was found to be a postoperative cruoric embolism with shock. The patient was stabilised, conscious, and then was transferred into the ICU. The outcome was good. Regarding the crisis resource management we could see that communication could have been improved (call for help was succinct: « come quickly » only without further information. On a positive note the hand-off process between the two anesthesiologists was simple and concise. The debriefing revealed that the ID has caused the colleague to believe that it was a device problem. He was aware of a previous patient’s death due to electric defibrillation during a routine operation. The patient had been shocked following activation of the ID by the electric scalpel. The ID had been mistaken with a pacemaker.

Good points : ● Teamwork● Other diagnosis● Avoid anchorage

Ways for improvement : ● Stop think and have a discussion before the procedure (situation point). I was lucky to be less involved in this case than my colleague. That’s probably one of the most interesting point when you call for help.● Teamwork is highly effective to avoid cognitive bias.● The “10s for 10 min principles” provide a short period of time to consider other diagnoses. The use of a cognitive aid is also a useful tool.● Clinical Recommendations provided by the ID manufacturer

Tomorrow I’ll change : ● Call for Help and say “who’s the leader ?”● Allocate tasks precisely to team members

KEYWORDS : defibrillator, fixation error, diagnosis




I DIDN’T SEE IT ! I was in the ophthalmology operating room. A patient had to be operated on under topical anesthesia for cataract surgery (Tetracaine drops). The patient was anxious so we injected intravenous propofol sedation. The surgeon encountered technical difficulties and complained throughout the operation that «the patient’s eye did not dilate well» ... His repeated complaints led me to check the products administered in drops by the scrub nurse. I discovered that the patient was given ONLY Tetracaine. He never got the phenylephrine that was supposed to dilate the pupil. The packaging was so similar that the nurse did not realise that he was administering the same medication twice. The usual procedure is that the administration of the drops must be done by the scrub nurse when not done previously. This situation increased significantly the workload for the nurse leading to her stress. Moreover the surgeon asked the nurse to «dilate» the patient’s eye but a right prescription could have been an effective way prevent this error (name the medication required).

Good points : ● Systemic analysis ● Wish to avoid new mistakes

Ways for improvement : ● Effective medication prescription● Allocate task equally to reduce the workload of the scrub nurse● Storage of drugs by pharmacological class (the two products, with very similar packaging, are stored in the same shelf in two transparent places one on top of the other)● Be aware of the weakness of the reading process

Tomorrow I’ll change : ● Avoid look alike drugs

KEYWORDS : medication, error, packaging, routine





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I NEED MY SPACE ! I finished my night shift. I was about to make hand-offs to my colleague. A V2014 certification visit was planned for the following week. He was checking the emergency obstetric OR. I opened the main door and I discovered that a new computer had been set up in the anaesthesia area in place of the anesthesia cart (anesthetic drugs and devices). This computer was dedicated to the scrub nurse (fill in different forms) and it was now close to the anesthesia station. Our cart was moved to the feet of the patient, causing «conflicts» and disorders during crisis code. We would have to move around and leave the patient’s « head » to prepare medications or infusions. I became very angry and immediately called the head midwife to remove this computer otherwise I would have to close this OR for safety reasons.

Good points : ● Report this problem● Threat of closure the OR for safety reason

Ways for improvement : ● Discussion with frontline staff before changing their workplace● Being aware that new rules and organisation can lead to new threats and safety issue.

KEYWORDS : equipment, communication, workplace




This feedback is emblematic of the concept of «usability» developed in ergonomics. It is wi-dely used in the medical device industry because it defines «the degree to which a product can be used, by identified users, to achieve defined goals with effectiveness, efficiency and satisfaction, within a specified context of use».

This concept can easily be applied to the medical environment of hospitals and more spe-cifically to the operating room. This standardised and collective workplace must meet the challenges:

- effectiveness to enable multiple users to achieve the desired outcomes for their patients,- efficiency by limiting everyone’s work and time to perform a surgical procedure,- satisfaction of the users who must evolve comfortably in this work environment.

In this case report, the rearrangement of the operating theatre was organised in a rush to meet the certification requirements without taking into account the usability components.

The setup of the computer on the anaesthesia side allows the patient’s computerised record to be filled in without compromising the efficiency of the environment. In this situation, this modification has profoundly decreased the efficiency of the operating room by requiring teams to work extra time and effort to reach their work tools.

Workflow is disrupted by the overlapping workspaces of the different healthcare givers, which may increase the risk of acquired infections and potentially interfere with communication between different participants during an emergen-cy. Integrating an ergonomic approach into the various work activities makes it possible to highlight where the risk is built up.

It’s not realistic to imagine having to program an ergonomic intervention to accompany each modification of the OR. Nevertheless, teamwork makes it possible to define the contributing factors that foster the efficiency of each user in the OR. The final user should participate in the resolution of the problem and submit a consensual solution that will take into account the imperatives of each one.

This collaborative process can be validated by testing the reorganization. Computer simulation or life-size tools are becoming more and more popular and must be used to evaluate the diffe-rent solutions proposed under normal and exceptional conditions.

Stéphane Kirche* and Alexandre Benoist *** biomedical engineer, CesiTech CH de Châlon sur Saône CEO

** biomedical engineer and CRNA





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What if we used common sense again ?

We live in a society in which interactions are becoming ever more complex, as there are many parties involved in our daily activities. In order to allow us to cope with this growing complexity, regulatory bodies have emerged. Their initial “raison d’être” is beneficial : to simplify – or streamline – the work of operators by providing them with procedures, protocols and other relevant cognitive aids. The goal, whether onboard an airliner, in an operating theatre or in a nuclear power plant, is to ensure the safety of our customers, whether they be passengers, patients or citizens.

In certain areas, public regulatory and certification bodies are gradually passing the torch to private institutions, whose profitability goals may take precedence over the primary mission. This is, for example, the case with international accreditation bodies which rank organizations on a reliability scale in exchange for a financial transaction. It seems that ethics are not often invited to take part in the debate.

In any case, this quest to simplify frontline staff’s many tasks reaches its goal only if it involves the staff concerned, because it alone knows its constraints and needs. Nowadays, in many fields, standards and rules are imposed on us by administrators who are far from frontline realities. This can result in dire situations, in which the ambition to meet regulatory requirements takes precedence over common sense, thereby hindering the safety of our customers.

In aviation, the Safety Management System (SMS) requires operators to carry out a Safety Evaluation before imposing any change to work methods. This study aims to identify the new risks introduced by the foreseen changes, in order to determine whether these are acceptable or not, and to introduce new barriers if deemed necessary.

Let’s keep in mind, as frontline operators, that we remain responsible ! For information, somewhere in the thick standard operating procedures manuals which govern the life of airline pilots, you can read this vital sentence : « The captain may decide to deviate from standard procedures if he considers it necessary in order to meet a safety requirement. »

Best practice: Turn down any bureaucratic requirement that jeopardizes the safety of our customers. Let’s keep asking ourselves this question: « What is best, here and now, for the safety of my patient ? ».

Guillaume Tirtiaux Airline pilot, author of the book “Mieux réussir ensemble”




IATROGENIC HYPONATREMIA I was the on-call anaesthetist in the pediatric operating room. A more experienced physician was supervising me as I was beginning my fellowship. It was unclear to me who was the leader. The team also had a CRNA. The patient was a three-month old child with pyloric stenosis. The surgery was delayed by 24 hours of fluid therapy. He weighed approximately 3 kg and was infused with a 500 ml G5% polyionic bag connected to a dialaflow device. The crush induction went well and the child intubated and ventilated. the procedure began without any problems. After a few minutes the CRNA noticed that the infusion bag was empty. I realised that the patient had accidentally received 300 ml of polyionic G5%, or 100 ml/kg of a hypotonic solution. I discovered that the child had an oedema of the eyelids. A blood sample was performed and found a critical hyponatremia at 118 mmol/l whereas it was normal in preoperative. We informed the surgeon and the child was transferred into the pediatric intensive care unit. After 24 hours in the ICU, the child recovered without any side-effects. We supposed that the dialaflow had been fully open at the time of induction to flush the drugs and had not been closed. This incident was reported in our incident reporting system without any feedback from management. We requested and did not receive appropriate solutions from the pharmacy. We wrote a protocol that remained «stuck» in the institutional review and validation procedures. A similar but less serious incident occurred some time later (the child weighed 9 kg). So we printed on A4 sheet «for children under 10 kg take RL 500 ml + 1 ampoule of 20 ml of G30% and use a volumetric pump», and displayed this in the OR.

Good points : ● Mitigation of damage (transfer into the ICU) ● Communication and debriefing with the team and the family● Frontline staff take action to prevent further accidents.

Ways for improvement : ● Hypotonic IV fluid bags. We should use « Ringer Lactate G1% »● Name the leader and allocate different tasks / threat and error management briefing● Use of safe devices (metriset or volumetric pump)

Tomorrow I’ll change : ● Speak up and say “Who’s the leader ?”

KEYWORDS : hyponatremia, dialaflow, hypotonic





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THE EGO, MY WORST ENEMY ! I started a gastrointestinal endoscopy shift as an anesthesiologist. I hadn’t worked in this environment for almost 10 years. I was biased and had a negative opinion about the skills of the previous physician and the CRNA. The gastroenterologist informed me that the next patient had a megaesophagus. A discussion started with questions about the need to perform an orotracheal intubation. Because I was concerned about the pulmonary aspiration, I decided to intubate the patient even if it was going to be a short procedure. I said to the CRNA that we would not use suxamethonium because it was contraindicated for short general anesthesia. Without thinking I suggested preparing the atracurium neglecting the possible risk of aspiration. The CRNA seemed to disagree but didn’t speak up. I repeated the general anesthesia protocol and she finally contradicted me stating that the pulmonary aspiration risk was very high due to esophageal stagnation.I suddenly realised that I had tunnel vision with an option that made no sense. I changed the protocol and we proceeded with the general anesthesia. An esophageal stasis of fluid was also found. After endoscopy the patient was extubated in the PACU after complete recovery. I decided to analyse what was the reason for this strange decision. I was stressed by the environment (unknown equipment, unknown operator, unknown CRNA,...). I wanted to impress everybody with my experience and knowledge.

Good points : ● CRNA Speak up ● Good choice using intubation procedure

Ways for improvement : ● Briefing before action to recover from bad decisions.● Listen to all team members● Consider level of overconfidence before action● Use high flow suction pipe

Tomorrow I’ll change : ● Promote “ speaking up” skill

KEYWORDS : aspiration, suxamethonium, speak up




DO WE HAVE TO MAKE TRADEOFFS REGARDING PATIENT SAFETY ? I was the head of the anesthesiology department. I finished my night shift so I was not authorised to perform any more anesthesia procedures. There were two anesthesiologists in the hospital . They were in the theatre (one with a child and the other one occupied by a C-section for acute fetal distress). Due to a heavy schedule, the gastroenterologist was in a hurry. I was looking for someone to proceed with a general anesthesia for his first patient. He called one of the physician who couldn’t come but he asked a CRNA to begin the procedure. The questions are : how could the CRNA manage a crisis situation with two physicians booked into the OR ? Who could assist the CRNA if he needed to call for help ?Is this behavior dangerous ? I argued strongly against the use of the CRNA with my colleague. He became angry and confirmed to me that he was doing this in other hospitals and that he would do it again if necessary. I was concerned thinking that that kind of “normalisation of deviance” could potentially expose patient safety issues.

Good points : ● Report this event

Ways for improvement : ● Resist to pressure to proceed● Debrief this situation with the team about what we should ban and what we could accept regarding patient safety issue.● Support non violent communication

Tomorrow I’ll : ● Read professional policies and rules● Define with all stakeholders a procedure to apply in this situation

KEYWORDS : workload, pressure to proceed, planned surgery

DEALING WITH THE UNMANAGEABLE I was on call in the E.R. at 2:00 am. A violent patient was admitted into the ER. The staff was inexperienced and recently graduated. The patient needed to be sedated with intranasal 10 milligrams of midazolam. I asked the nurse to prepare two midazolam ampoules. He filled a syringe with two midazolam ampoules and I injected the whole amount. The patient quickly became very drowsy but hopefully without respiratory distress. I realised that we had injected 100 milligrams of midazolam. Many factors contributed to this incident. The team was stressed by the patient’s violence. The nurse seemed panicked and we did not effectively close the loop. We should have checked if there was some doubt about the right prescription. The nurse should be encouraged to speak up and express their concerns even if it was regarding the chief medical officer.

Good points : ● Reporting this event

Ways for improvement : ● Closed-loop process for any drug prescription especially in case of an emergency.● Avoid or ban the use of two different concentration of the same drugs in a ward (midazolam 50 mg/5 ml ou 5 mg/5 ml)● Promote the “speak up” process

Tomorrow I’ll : ● Communicate more accurately ● Debrief this case and consider how to secure medication prescription during crisis code.

KEYWORDS : emergency, prescription, medication overdose





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IN-SITU INCIDENTI was on call in the ICU. Someone called for help for with a patient who was in a coma in the surgical ward. When we arrived we discovered the patient on the floor in the corridor. I asked « Is she breathing ? » and they said « No ». No-one had begun cardiopulmonary resuscitation and the DSA wasn’t plugged in. We started CPR. The etiology of the cardiac arrest seemed to be due to a food-related choking. I asked for a suction pipe and we waited for about 5-7 minutes to get a functional one. We intubated the patient who eventually passed away (major psychiatric disorder). When it came to analyse this event I noticed that the patient was at the door of her room and therefore was too far away from the wall with suction device. Moreover, the environment could have been optimised by moving the patient back to her room or by placing her in the corridor. I decided to organise a morbidity and mortality review to struggle with this situation and the crash cart .

Good points : ● Call for help● Allocate workload

Ways for improvement : ● Diagnosis of cardiac arrest● First steps to perform in case of a cardiac arrest● Check crash cart regularly

FAKE HYPERGLYCEMIA This particular week seemed to be endless. The first case of the day was a diabetic patient. I was concerned about this patient with a long history of heart disease and a stroke. The patient had a low BP at the beginning of the surgery, making it questionable whether his hypotensive medication had been taken. He was a high risk for neurological and infectious complications. I also had to regularly check for blood glucose levels. The first one was at 2.4 g/l. I had to get under the surgical blanket in order to perform the measurement of blood glycemia (cervical spine surgery). The PACU nurse told me that it was very difficult to use it properly due to many dysfunctions. Then I performed the puncture and switched on the device. A message indicated on the screen « put the drop of blood » during a long time. Then the number 222 was displayed. I read 222 as if it was 2.22 g/l. So, I administered an IVD insulin injection. Thirty minutes later, I decided to check the blood glucose level and the same thing occurred « 222 ». I realised that I had probably misunderstood the message. It was a code error (in the corner of the glucometer screen was written « CODE » but I wasn’t aware of that. Finally, the new measurement revealed a glycemia of 1.7 g/l. I was very tired from an evening meeting that had ended at 1:00 am. Regarding this case, I should have discussed in more detail with the PACU nurse about the use of this device. Moreover, I should have called for help when I was in trouble. My brain wanted a blood level measurement and when « 222 » popped-up, my brain took it for granted without trying to find or read other information written on the glucometer screen (CODE).

Good points : ● Diagnosis of mistake● Report the incident

Ways for improvement : ● The ergonomics of the device needs to be redesigned. My brain was waiting for a number. The code was what I expected so I took it for real.● No visualisation of the message indicating that it was an error code and not a measurement number.● I should have had further discussions with the nurses on the use of this device● The difficulty of going under the fields did not help to do the glycemia measurements with serenity.● Report this case to the manufacturer because there are many ergonomic issues (what if it was a patient with a diabetic retinopathy ?). That’s more about a «use error» than a «user error

Tomorrow I’ll : ● Throw away this device due to a high risk of recurrence.

KEYWORDS : check, glycemia, design

Tomorrow I’ll : ● Practice in-situ simulation trainingl● Morbi and mortality review

KEYWORDS : CPR, equipment, crisis code




ARE YOU READY TO DEAL WITH A FIRE IN THE OR ?

A 57-year-old patient was operated on for a tumorous lesion of the plantar arch. General anaesthesia was performed with the application of a laryngeal

mask, deep resection of the margins and then preparation for the application of a VAC type aspirative dressing for directed cicatrisation. At the end of the procedure,

a medical representative suggested to the surgeon that a non-irritating protective skin film be placed on the wound.

Before applying the VAC type occlusive dressing, the surgeon performed a small coagulation with an electric scalpel on the edges of the wound: the protective film ignited instantaneously,

as did one of the gloves of the (resident) surgical assistant who was holding a piece of the film between his fingers. The scrub nurse quickly threw the contents of a saline cup that was on the table onto the wound and extinguished the flame on the sterile blanket. The resident got rid of his burning glove and threw it into the trash can, which immediately caught fire. The fire in the trash can was quickly extinguished by smothering the flame. The cognitive aid sheet «Fire in the Operating Room» was not consulted. The team did not alert the head nurse or the anaesthetist in charge of the patient as they considered this case as a «non-event» since it had no immediate consequences. After writing his operative report, the surgeon brought to the OR manager the packaging of the incriminated product on which the «flammable product» logo was affixed. There was no information transmitted to the users. An adverse event sheet was drawn up and the anesthesiologist was informed of the incident at the end of the day by the CRNA during a informal debriefing.

Good points : ● Mitigate patient damage● Quick reaction to fire management

Ways for improvement : ● Being aware about the importance to report minor incident or near-misses● Training session to deal with fire in the OR (use of cognitive aid)● Read all the informations about a new equipment or productr

Tomorrow I’ll : ● Make a debrief and organise a morbidity and mortality review

KEYWORDS : fire, procedure, equipment





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TAKE HOME MESSAGES

• ●Be proactive in your activities and be aware of expected risks.

• ●Use feedback as a way to become aware of and learn how to manage unimagined risks.

• ●Establish the easiest possible procedures with all actors, including frontline staff

(Keep It Simple Stupid : KISS)

• ●Use incidents to check your barriers to recover from unusual situations.

A day at the British Airways training center to train medical doctors to hu-man factors

I heard about this human factors trai-ning in healthcare during a seminar at the Royal College of Surgeons. It’s held in the British Airways centre at Lon-don Heathrow. Trainetics is a company that combines medical and aeronauti-cal expertise. It offers a series of one-day courses and workshops. Topics are oriented towards the frontline staff and teamwork: situation awareness, decision making, managing the hierarchy gra-dient, managing distractions.The end of each course is devoted to an interaction with the speakers, enriching our reflection. The tone is humble and despite their experience in their respec-tive fields, the trainers remain very open to discussion. A «take home message»

toolbox summarises each module. After a coffee break, we move on to the flight simulators. The session lasts 60 mi-nutes in an Airbus 320 simulator with a landing exercise at London Heathrow Airport. We then work on task assign-ment, measuring our errors due to mul-titasking. The emotional impact of this life-size experience leaves an unforget-table impression on our minds. At the end of the morning, it’s the session in the commercial cabin simulator with BA stewards. We are involved in the care of a sick person during a long distance flight. We practice teamwork, space ma-nagement and information gathering in

a poor environment. During the lunch break, it is an opportunity to exchange our experiences with the other trainees. In the afternoon, two workshops are gi-ven in succession on distractions and the non-punitive culture of error («just culture»). This training brings theoretical and practi-cal notions that will enrich your non-tech-nical skills. It is also a great human expe-rience. A correct level of English is required in order to participate in the exchanges and to fully benefit from them.

Docteur Lopes ThomasPrivate pilotAnesthesiologistFacteurs Humains en Santé co-founder

TRAINETICS




WANT TO FIND OUT MORE

NEXT MEETINGS

The ESA Patient Safety Policy Summit, March 3-4 ,2020, Bruxel https://www.esa2020.org/ JEPU 2020, les 27-28 Mars ,2020, Paris. https://www.jepu.net/ International Forum on Perioperative Safety & Quality, May 29 ,2020, Barcelona. https://euroanaesthesia2020.org/isq/ Euroanaesthesia, May 30 au - June 1 ,2020, Barcelona.

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● Eurocontrol Hindsight 29 - Goal conflicts and trade-offs. Winter 2019 https://www.eurocontrol.int/publication/hindsight-winter-2019●

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APSF - Prevention and management of operating room fire https://www.apsf.org/videos/or-fire-safety-video/

Facteurs Humains en Santé YouTube channel (short videos in French) https://www.youtube.com/channel/UCXRx2Vq521jeo9o4l0KtOCA/featured

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https://www.esa2020.org/

https://www.esa2020.org/

https://www.jepu.net/

https://euroanaesthesia2020.org/isq/

https://www.eurocontrol.int/publication/hindsight-winter-2019

https://www.apsf.org/videos/or-fire-safety-video/

https://www.youtube.com/channel/UCXRx2Vq521jeo9o4l0KtOCA/featured

Documents

PATIENT SAFETY REPORT€¦ · possible or desired, please at least consider eating break-fast and lunch during a working day. Omitting a meal to lose weight should be discouraged