A Human Factors Engineering Study of the Medication Delivery Process during an Anesthetic

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Medication safety in nonoperating room anesthesiology

PURPOSE OF REVIEW

Medication errors remain a prominent source of medical harm in spite of over 20 years of effort in establishing standardized protocols and procedures, implementing assistive electronic technologies to identify medications and prevent administration errors and in establishing a just culture with regard to reporting events and near misses.

RECENT FINDINGS

Some of these interventions are even more necessary in the nonstandard environment of a non-operating room anesthesiology (NORA) procedure suite, where the anesthesiologist is often far removed from colleagues, in a dark room, lacking the standard medications commonly found in their operating room. Medication availability in NORA sites may be limited because of lack of standardization or distance from the operating room pharmacy. Proper preparation of medication may be impaired by poor lighting and cramped conditions. Medication administration might be hampered by a lack of infusion pumps or pumps without the proper medication library needed by the anesthesiologist.

SUMMARY

Specific attention must be paid to enhancement of medication safety in NORA sites to overcome additional challenges inherent in the provision of anesthesia care remote from the standard operating room setting.

Risk of Patient Harm Related to Unnecessary Dilution of Ready-to-Administer Prefilled Syringes: A Literature Review

Unnecessary dilution of ready-to-administer (RTA) syringes could increase the risk of patient harm attributed to errors related to incorrect dose, improper labeling, and the potential for microbial contamination. Although published guidelines endorse the use of commercially available RTA syringes, recent surveys indicate that best practices are not always implemented. The purpose of this article is to review the existing literature and to assess the incidence and nature of errors related to the unnecessary dilution of RTA intravenous (IV) push medications in the inpatient clinical setting. The PubMed database was searched to identify studies of errors related to the use of RTA syringes for IV push medications within the last 10 years. An additional search was conducted using other search engines to identify relevant articles in the grey literature. This literature review concludes that unnecessary dilution of IV push medication in RTA syringes is an unsafe practice that occurs routinely. This practice increases the risk of patient harm through errors related to incorrect dose, improper labeling of syringes, and the potential for microbial contamination of the product. Greater awareness of the risks associated with unnecessary dilution of RTA syringes is still needed to eliminate this unsafe IV push medication administration practice and to thereby further improve outcomes.

Work systems analysis of sterile processing: assembly

BACKGROUND

Sterile processing departments (SPDs) play a crucial role in surgical safety and efficiency. SPDs clean instruments to remove contaminants (decontamination), inspect and reorganise instruments into their correct trays (assembly), then sterilise and store instruments for future use (sterilisation and storage). However, broken, missing or inappropriately cleaned instruments are a frequent problem for surgical teams. These issues should be identified and corrected during the assembly phase.

OBJECTIVE

A work systems analysis, framed within the Systems Engineering Initiative for Patient Safety (SEIPS) model, was used to develop a comprehensive understanding of the assembly stage of reprocessing, identify the range of work challenges and uncover the inter-relationship among system components influencing reliable instrument reprocessing.

METHODS

The study was conducted at a 700-bed academic hospital in the Southeastern United States with two reprocessing facilities from October 2017 to October 2018. Fifty-six hours of direct observations, 36 interviews were used to iteratively develop the work systems analysis. This included the process map and task analysis developed to describe the assembly system, the abstraction hierarchy developed to identify the possible performance shaping factors (based on SEIPS) and a variance matrix developed to illustrate the relationship among the tasks, performance shaping factors, failures and outcomes. Operating room (OR) reported tray defect data from July 2016 to December 2017 were analysed to identify the percentage and types of defects across reprocessing phases the most common assembly defects.

RESULTS

The majority of the 3900 tray defects occurred during the assembly phase; impacting 5% of surgical cases (n=41 799). Missing instruments, which could result in OR delays and increased surgical duration, were the most commonly reported assembly defect (17.6%, n=700). High variability was observed in the reassembling of trays with failures including adding incorrect instruments, omitting instruments and failing to remove damaged instrument. These failures were precipitated by technological shortcomings, production pressures, tray composition, unstandardised instrument nomenclature and inadequate SPD staff training.

CONCLUSIONS

Supporting patient safety, minimising tray defects and OR delays and improving overall reliability of instrument reprocessing require a well-designed instrument tracking system, standardised nomenclature, effective coordination of reprocessing tasks between SPD and the OR and well-trained sterile processing technicians.

Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

Intubation drug pack containing pre-filled syringes reduces the time to endotracheal intubation in a simulated paediatric emergency

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p<0.001), allowing intubation to occur on average 5 min and 38 s earlier. Utilising an intubation drug pack containing pre-filled syringes significantly reduced the time from decision to intubate to intubation in a simulated paediatric emergency. This applied irrespective of clinical experience with registrars utilising the pre-filled syringes outperforming consultant anaesthetists when they used standard care.

Molecular recognition of methamphetamine by carboxylatopillar[5]arene: drug-dependent complexation stoichiometry and insights into medical applications

The molecular recognition of the carboxylatopillar[5]arene on methamphetamine showed interconversion between H₂:G ⇋ H:G stoichiometries with dependence on drug concentration.

The role of human factors in neonatal patient safety

The relationship between the fields of human factors and patient safety is relatively nascent but represents a powerful interaction that has developed in only the last twenty years. Application of human factors principles, techniques, and science can facilitate the development of healthcare systems, protocols, and technology that leverage the enormous and adaptable capacity of human performance while acknowledging human vulnerability and decreasing the risk of error during patient care. This chapter will review these concepts and employ case studies from neonatal care to demonstrate how an understanding of human factors can be applied to improve patient safety.

Work systems analysis of sterile processing: decontamination

BACKGROUND

Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes.

OBJECTIVE

In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.

METHODS

The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix.

RESULTS

We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries.

CONCLUSIONS

Ensuring patients and technicians' safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.

A Work Systems Analysis of Sterile Processing: Sterilization and Case Cart Preparation

Achieving reliable instrument reprocessing requires finding the right balance among cost, productivity, and safety. However, there have been few attempts to comprehensively examine sterile processing department (SPD) work systems. We considered an SPD as an example of a socio-technical system - where people, tools, technologies, the work environment, and the organization mutually interact - and applied work systems analysis (WSA) to provide a framework for future intervention and improvement. The study was conducted at two SPD facilities at a 700-bed academic medical center servicing 56 onsite clinics, 31 operating rooms (ORs), and nine ambulatory centers. Process maps, task analyses, abstraction hierarchies, and variance matrices were developed through direct observations of reprocessing work and staff interviews and iteratively refined based on feedback from an expert group composed of eight staff from SPD, infection control, performance improvement, quality and safety, and perioperative services. Performance sampling conducted focused on specific challenges observed, interruptions during case cart preparation, and analysis of tray defect data from administrative databases. Across five main sterilization tasks (prepare load, perform double-checks, run sterilizers, place trays in cooling, and test the biological indicator), variance analysis identified 16 failures created by 21 performance shaping factors (PSFs), leading to nine different outcome variations. Case cart preparation involved three main tasks: storing trays, picking cases, and prioritizing trays. Variance analysis for case cart preparation identified 11 different failures, 16 different PSFs, and seven different outcomes. Approximately 1% of cases had a tray with a sterilization or case cart preparation defect and 13.5 interruptions per hour were noted during case cart preparation. While highly dependent upon the individual skills of the sterile processing technicians, making the sterilization process less complex and more visible, managing interruptions during case cart preparation, improving communication with the OR, and improving workspace and technology design could enhance performance in instrument reprocessing.

Paralyzed by Mistakes - Reassess the Safety of Neuromuscular Blockers in Your Facility

Neuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.

Interactional Resources for Quality Improvement: Learning From Participants Through a Qualitative Study

BACKGROUND

Implementing quality improvement in hospitals requires a multifaceted commitment from leaders, including financial, material, and personnel resources. However, little is known about the interactional resources needed for project implementation. The aim of this analysis was to identify the types of interactional support hospital teams sought in a surgical quality improvement project.

METHODS

Hospital site visits were conducted using a combination of observations, interviews, and focus groups to explore the implementation of a surgical quality improvement project. Twenty-six site visits were conducted between October 2012 and August 2014 at a total of 16 hospitals that agreed to participate. All interviews were recorded, transcribed, and coded for themes using inductive analysis.

RESULTS

We interviewed 321 respondents and conducted an additional 28 focus groups. Respondents reported needing the following types of interactional support during implementation of quality improvement interventions: (1) a critical outside perspective on their implementation progress; (2) opportunities to learn from peers, especially around clinical innovations; and (3) external validation to help establish visibility for and commitment to the project.

CONCLUSIONS

Quality improvement in hospitals is both a clinical endeavor and a social endeavor. Our findings show that teams often desire interactional resources as they implement quality improvement initiatives. In-person site visits can provide these resources while also activating emotional energy for teams, which builds momentum and sustainability for quality improvement work.

IMPLICATIONS

Policymakers and quality improvement leaders will benefit from developing strategies to maximize interactional learning and feedback for quality improvement teams. Further research should investigate the most effective methods for meeting these needs.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

Aggrastat-Argatroban Mix-ups Don't Expect Radiofrequency Identification Stock Systems to be Perfect Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs.

Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.