NWAC Patient Safety Pearls Archive

Week ending:  September 28th, 2013​

Anesthesiologist: Sanford Littwin MD

Assistant Professor of Anesthesiology

College of Physicians and Surgeons Columbia University

Deputy Director of Anesthesia

St. Luke's and Roosevelt Hospitals

New York, NY 

Preventative measure/tip: Labeling of syringes with medications

Labeling of syringes is a paramount for the safer practice of anesthesia. With the exception of propofol, most dissolved medications are colorless making them indistinguishable in a syringe from one another.

Even when in vials, medications could easily be mistaken for each other if a strict procedure of reading the vials and labeling syringes is not followed.

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We use daily pre-printed set of labels for commonly used drugs:​

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The advantage of fresh-printed labels is that it includes the date stamp, color coding and avoids the perils of undecipherable hand-writing on the syringe as a method of labeling. A purchase of a single, low-cost color laser printer to print labels daily made a huge difference in our practice.

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photo4 Sep 28th feature.jpg Simple, effective, and a minor change to your usual "quick" practice of placing labels on syringes!!!


Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

Visit our archives for previous NWAC Patient Safety Pearls

 

Week ending:  September 21st, 2013

Admir Hadzic 

Anesthesiologist: ​Admir Hadzic, MD, PhD

USA

 

Preventative measure/tip: Checklist use

The checklists have become a common place in the operating room. Check lists are being implemented throughout the patient pathways with a goal to reduce therapeutic, diagnostic, medication and clerical errors. Some physicians however claim that their indiscriminate "over-implementation" has drawbacks (desensitization, distraction from patient care, inefficiency). Share your views on when and where the checklists are useful and examples where they are not.  

photo 5Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

Visit our archives for previous NWAC Patient Safety Pearls



Week ending: August 30th, 2013

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Anesthesiologist: Stavros Prineas

Australia 


Preventative measure/tip: Easy respiration monitoring during endoscopy​

Doing an endoscopy and want to monitor respirations easily? You don't have those nasal prongs with the CO2 sampling connector? Instead of attaching the oxygen to the mouthguard, try connecting the CO2 sampling line instead and use nasal prongs to supply the oxygen (Fig 1). Most of the time you will get an excellent respiratory trace (Fig 2), especially once the endoscope has been inserted.

 

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                          Fig. 1                                                                                        Fig. 2​


 

Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

Visit our archives for previous NWAC Patient Safety Pearls​

 


Week ending: August 24th, 2013

 

Jason Choi

Staff Anesthesiologist

Santa Clara Medical Center

Kaiser Permanente

 

Ultrasound-Guided Peripheral Nerve Blocks : Safety Tips

  1. Resistance to Injection (Opening Injection Pressure)

    

High opening injection pressure (>15 psi) has been associated with intrafascicular needle placement in several studies in animals and human tissues. Clinicians have always subjectively assessed resistance to injection. Perineural injection should be seamless and have low resistance given that surrounding perinueral adipose tissue is highly compliant.

 

Tips on monitoring injection pressure:

  1. Pressure Point: The critical monitoring point is the Opening Injection Pressure, which is the pressure required to initiate the injection. The idea is that if the injection is aborted before a high opening pressure is reached (<15 psi), then an injection is prevented altogether into a dense (low compliance) tissue medium.

    Here's an example from Orebaugh et al. RAPM 2013 – all injections into roots of brachial plexus resulted in opening pressure >20 psi.

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Opening Injection Pressure has a high rate of false positive alarms, as high injection pressure can be observed with an injection into any poor compliance tissue (tendon, fascia, clotted needle) - not only into nerve fascicles. Remember:  while injection pressure is not specific for nerves, it is 100% sensitive – an injection into a low compliance tissue will always be detected by high opening pressure.

2. Multiple Injection: Injection Pressure monitoring is not affected by multiple injections.

3. Size Doesn't Matter: Size of needles (25-18g), length of needles or speed of injection does not affect the opening pressure monitoring (Pascal's Law).

4. Slow And Steady: Methodical injection while keeping the injection pressure at < 15 psi throughout the entire injection process assures injection into a high compliance tissue (normal).

5. Low Specificity: One limitation of this technique is that high opening pressure can occur due to a variety of anatomical or injection technique factors.

6. Advantages: High sensitivity, strong/objective medico-legal documentation.

More reading material on injection pressure and means to monitor opening injection pressure: International Anesthesiology Clinics, 2011; 49:67-80.

 

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Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

 Learn with us and find out what's the latest NWAC Patient Safety Pearl this week

 


Week ending: August 17th, 2013

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Anesthesiologist: Stavros Prineas

Australia 

 

What's the first electronic monitor you should routinely attach to your patient?

 

I've noticed that many anesthetic nurses and operating department assistants in various places where I work put the ECG on first, then the NIBP, then the oximeter. I suspect this is because historically this was the order in which these monitors became widely available, and often people don't really think about whether there's an optimal order in which to apply the monitoring. 

Of course the monitor that gives you the most useful information about the global state of the patient most quickly is.... the pulse oximeter. As well as oxygent saturation, the waveform gives information about heart rate, rhythm and quality of perfusion. 

Applying ECG dots and an NIBP can take up at least half a minute. 30 seconds is a long time in Hypoxialand. Applying an oximeter probe takes a few seconds. If staff were trained (and reminded) to routinely put the sats on first, they'd quickly learn to do it habitually without thinking. In an emergency this may give you a useful heads-up while the other monitors are being attached.  

PS. if I had to choose the second most important electronic monitor today, I'd say... the capnograph, especially in patients with an ET tube or an LMA. In fact, where many colleagues use the default monitoring display (with the ECG on the top), I routinely reconfigure it to put what I consider the most important information at the top - the oximeter, followed by the capnograph, then the ECG, because this actually helps me "read the screen" more quickly. In the right order the words it's like reading…!

Others may find a different configuration more useful. The point is, don't assume that the default settings are the optimal settings. Experiment. Play. Find out what works best for you.

Finally don't forget that the most important monitoring device of all is still… you!!

 

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Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

 Learn with us and find out what's the latest NWAC Patient Safety Pearl this week

 

Week ending: August 10th, 2013

 

Anesthesiologist: Jason Choi

Santa Clara Medical Center

Kaiser Permanente

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Preventative measure/tip: Ultrasound-Guided Peripheral Nerve Blocks Series, 1st out of 4

 

ULTRASOUND: An ultrasound visually monitors the needle-nerve relationship as well as the distribution of the injected local anesthetic.

 

Here are a few important tips to keep in mind when using ultrasound for regional anesthesia: 

 

  • Do Not Fly If You Cannot See!  Using an ultrasound requires fly-by-vision.                 

Remember:  If you do not see the needle and target clearly, do not advance the needle 

 

  • The Color Of Safety: Use color-Doppler to scan highly vascular areas so as to decrease the risk of vessel puncture.
     
  • Seek The Spread: An injection of local anesthetic must result in a detectable spread in the desired tissue plane.                                                                                                     

 Remember: If no spread is seen, stop injecting: you could be injecting intravascularly! 

 

  • Needle With Care: For most nerve blocks, one or two needle positions are adequate to accomplish a successful block. Avoid multiple needle redirections, excessive needling and multiple injections.                                                                                                    

Remember: every needle insertion carries a risk of nerve or vessel puncture, hematoma or nerve injury. 

 

  • Ultrasound To A Point: Some limitations on the use of ultrasound include:
      • The reliability and safety of ultrasound is heavily dependent on sono-anatomy as well as the operator's skill level.
      • Ultrasound is a poor documentation tool.  While images of needle-nerve distance and injection spreads are accurate and should be saved, images of multiple attempts using inadequate techniques should be discarded.

Advantages: Ultrasound is the only practical tool to monitor the spread of LA.

Disadvantages: Operator and anatomy-dependent. Therefore – combine with nerve stimulation and monitoring of the resistance to injection.

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Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

 Learn with us and find out what's the latest NWAC Patient Safety Pearl this week

 

 

Week ending: August 3rd, 2013

 

Anesthesiologist: Sanford Littwin MD

Assistant Professor of Anesthesiology

College of Physicians and Surgeons Columbia University

Deputy Director of Anesthesia

St. Luke's and Roosevelt Hospitals

New York, NY 

 

 

Preventative measure/tip: Prevention of post-operative corneal abrasion

 

Background: Post-operative corneal abrasions (CA) are caused by several factors. The good news is that many of the circumstances surrounding CAs can be easily mitigated. Basic diligence to patient care along with a number of simple safety tips can instantly be implemented that will decrease corneal abrasion occurrences.

For example, the culprit in many CAs is the disposable pulse oximeter (Nelcor, Masimo, Invivo). This hard plastic material, acting as an extension of the patient's finger, can cause injury – especially given the patient's groggy state. The inadvertent "rubbing of one's own eyes" upon awakening from the effects of either general anesthesia or sedation is an all-too- common scenario in the PACU.

 

Solution: A quick and effective method for prevention is to place the pulse oximeter on a finger that is rarely used to rub one's eyes with: the ring finger.

Not convinced? Try it yourself:  rub your own eyes with your thumb, pointer, middle and pinky finger. Then, try doing the same with your ring finger.

As you'll see, it is far less likely that a patient would use that digit to scratch, itch or rub.

This easy fix is one way to reduce the risk of your patients suffering a corneal abrasion.

Hopefully, such tips - along with constant vigilance - will limit the amount of patients who leave the hospital with an unfortunate souvenir: a post-operative corneal abrasion.
 
 

 

 

Disclaimer: NWAC does not take responsibility for the results in the practice and application of our tips. These only intend to inspire colleagues and the sharing of best practices.

 

 Learn with us and find out what's the latest NWAC Patient Safety Pearl this week

   

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