Christopher L. Pysyk

Differentiating muscle relaxant syringes to reduce syringe swap error

To the Editor, Despite efforts to increase the availability and use of medication labels in anesthesiology practice, syringe swap errors continue to be an issue. Syringe swap errors of particular concern to patients and anesthesia providers involve unintended neuromuscular blocking agent administration before sufficient hypnosis has been provided. Using a perioperative incident reporting system, Gisvold and Fasting showed that 27 of 28 (98%) syringe swaps involved syringes of the same size, with the majority of these reports related to neuromuscular blocking agents given at induction of general anesthesia. Taken together, syringe swap error at induction involving muscle relaxants prompted the authors to comment that ‘‘special preventive measures should be taken to reduce errors in this group of drugs’’. With these results in mind, one must wonder if the size and shape of the syringe, despite being appropriately prepared and labelled, may contribute to such observations. Modification of a labelled syringe by taping the empty medication vial to the syringe barrel (Figure) may be useful to provide distinctive visual and proprioceptive feedback prior to administration of a muscle relaxant, particularly in the context of anesthesia induction where numerous different medications (often prepared in similar-sized syringes) are given in a relatively short time frame. Though formal studies have not been conducted regarding the efficacy of taping the empty medication vial to the syringe containing a neuromuscular blocking drug, this low-cost, visual, and proprioceptive modification shares thematic similarities with and builds upon the:

A change to the surgical safety checklist to reduce patient identification errors

To the Editor, Most near misses and events with harm to a patient arising from identification (ID) errors are thought to be preventable. In a large Canadian tertiary care hospital, more than 6% of surgical patients had their ID bands removed – most commonly for vascular line access – during their time in the operating room (OR). Not surprisingly, the competing and dynamic demands involved with providing intraoperative care may lead the OR team to defer replacing the ID band until later in the case. The risk of this practice is the propensity for timedeferred actions to be forgotten. Indeed, of those patients with ID bands removed, 60% did not receive a replacement band during the remainder of their time in the OR. If the ID band is not replaced before transferring the patient from the OR to the postanesthesia care unit (PACU) or intensive care unit (ICU), an impaired patient (pharmacologically from the anesthetic drugs and/or the surgical/disease state) arrives in a different clinical area with staff who are unable to confirm the patient’s identity – one of the most critical aspects of subsequent care. A series of cases involving patients arriving in the PACU without an ID band was entered in our hospitalwide, voluntary reporting system (Patient Safety Learning System, Datix Ltd., London, UK). Our multidisciplinary Quality and Patient Safety (QPS) Committee, consisting of an anesthesiologist and other allied perioperative health professionals, reviewed the cluster of these ID events and suggested a change to our Surgical Safety Checklist (SSC). We sought an institutional ethics review and subsequently received a waiver for individual patient consent because of the quality improvement nature of the committee and its work. Our checklist, modelled after the World Health Organization’s SSC, consists of three parts: ‘‘before induction of anesthesia’’ (i.e., brief), ‘‘before skin incision’’ (i.e., time out), and ‘‘before patient leaves operating room’’ (i.e., debrief). Following QPS Committee discussion, we decided that the final (debrief) part of the SSC was a reasonable time point at which to verify that the patient is wearing an ID (and allergy) band before transferring him or her to a different care area (e.g., PACU or ICU). During the six months after this change to our SSC, and with similar OR case volumes, no further events involving arrival of patients in the PACU or ICU without an ID band were reported in our Patient Safety Learning System. According to the hierarchy of effective strategies to guard against system threats, checklists offer a more favorable approach than education or messaging alone. This report highlights the utility of an established process – such as event review via a QPS Committee – to facilitate a local response to perioperative patient safety challenges.

In reply: Another easy method to reduce syringe swapping

To the Editor, I thank Dr. Bloria for describing another possible way to reduce medication errors involving muscle relaxants in the perioperative environment. Placing the empty medication ampoule over the capped needle does change the appearance of the needle-syringe complex compared with other syringes not prepared in this manner. Nevertheless, in situations where the needle cover and ampoule are removed en bloc for the syringe to access the intravenous injection port, any potential benefit gained from physical and/or visual identification of the muscle relaxantcontaining syringe, when prepared as described by the author, would no longer be present. Given that the majority of syringe swap errors involve muscle relaxants and occur at anesthesia induction (where a large number of medications are administered in a short period of time), it is not uncommon, for example during rapid or modified rapid sequence induction, to handle several syringes with needles and caps removed to facilitate rapid administration of the induction medications. In this setting (with needle cap and ampoule removed) the muscle relaxant syringe, as described, would only have the affixed drug label as the sole method of verifying the syringe contents immediately before administration. In contrast, taping the empty medication container (ampoule or vial) to the barrel of the syringe maintains the distinguishing visual and physical characteristics of the muscle relaxant syringe throughout the medication administration sequence.

Performance feedback in anesthesia: a post-implementation survey

To the Editor, The growing use of electronic medical records has provided a wealth of clinical data from which objective indicators of the quality of perioperative care can be drawn. Development of such indicators of quality and performance could result in potential methods to support more meaningful professional development. Unfortunately, optimal indicators of the quality of anesthetic care and how to use such data to provide formal performance feedback remain ill-defined. In an effort to identify clinical indicators and provide relevant performance feedback to anesthesiologists at The Ottawa Hospital, we developed the 2013 Performance Assessment. The data fed back were extracted from a preexisting prospectively collected data set from our local electronic medical record system (Ottawa Health Services Network Research Ethics Board (REB) 20120828-01H). Each anesthesiologist was provided data relating to their individual clinical practice. Metrics in the report included demographic characteristics of their practice, postanesthesia care unit (PACU) outcomes (i.e., pain, nausea, length of stay), and practice information relevant to those outcomes (e.g., analgesia, antiemetic use). Summary data on the same variables for the department as a whole were provided as a comparator. A sample 2013 Performance Assessment and the 2016 update can be viewed at 10.6084/m9.figshare.4291157.v1. To determine user-acceptability of the assessment and to highlight areas of potential improvement for future assessments/feedback, a post-implementation survey was administered to all recipients of a 2013 Performance Assessment (REB 20140438-01H). This 12-item survey, validated using Burns’ clinical sensibility testing tool in a pilot user group, was administered in in both electronic and paper formats. All eligible participants were given a copy of their personal 2013 Assessment along with a notice of the survey. Two e-mail invitations and distribution of a paper questionnaire were sent during the following sixweek period. The close-ended responses were assigned a numerical value to generate increased response frequency. Open-ended or free-text responses were categorized into general themes. Among the 76 eligible faculty, 52 (70%) submitted completed questionnaires, all electronic. Respondent perceptions of the performance assessment tool are demonstrated in the Table. Among the 52 (69%) participants, 36 (69%) agreed that this type of feedback is useful for professional development, suggesting a reasonable level of user acceptability. Whereas 34 of the 52 (65%) respondents indicated that the results of the performance assessment would influence their practice, 42 of the 52 (80%) respondents were neutral or disagreed that the tool was an effective measure of performance, and 22 of the 52 (42%) respondents were neutral or disagreed with questioning about physician autonomy. The latter responses suggested that some participants were uneasy with the assessment process and its potential implications. K. Wheeler, MD A. Baxter, BMBS, MA S. Boet, MD, PhD C. Pysyk, MD G. L. Bryson, MSc, MD The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada

Risk of look-a-like equipment in anesthesiology: it’s not just medications

The risk of safety events with look-a-like medication names, labels, and containers has been well described. Not commonly recognized, however, is the risk that look-a-like equipment may pose. Discussed below are two equipmentrelated, look-a-like threats reported to a hospital-wide, voluntary reporting system using the Patient Safety Learning System (PSLS; Datix Ltd., London, UK). In both cases, the information entered in the PSLS was reviewed by a multidisciplinary Quality and Patient Safety (QPS) Committee consisting of anesthesiologists and other perioperative allied health professionals. After discussing the events, a management plan was undertaken for each circumstance.

Dental protection with a padded laryngoscope flange

To the Editor, Perioperative dental injury remains a source of concern for patients and anesthesiologists. A recent prospective, observational study of 536 patients assessing dental status before and after tracheal intubation identified enamel fracture as the most common perioperative dental injury. It occurred in 82 (15%) of the 536 patients intubated by direct laryngoscopy. Not surprisingly, the teeth most likely to experience enamel fracture are the anterior maxillary incisors. Previously published techniques to mitigate dental injury during laryngoscopy including the use of dental guards and covering the laryngoscope flange with compressible, adhesive padding have been described. A low-cost modification of the latter method of dental protection for patients undergoing laryngoscopy involves application of gauze to the flange of the laryngoscope blade. The method is simple. Fold one gauze pad into quarters longitudinally (creating a 1 9 4 cm pad) (Fig. 1). Then, tape the folded gauze pad onto the flange of the laryngoscope blade i.e., where it is most likely to interface with the teeth during laryngoscopy (Fig. 2). Thus, a low-profile, non-metallic surface (gauze and tape) has been created with which the enamel of the maxillary teeth may be in contact during laryngoscopy. Although there are alternative methods of dental protection, such as dental guards, these devices may reduce the amount of oral space available for airway visualization in what could be an already-limited oropharynx. The advantage of gauze protection is that it attaches to the flange of the laryngoscope blade such that dental protection is provided where needed without obstructing insertion of the laryngoscope or the laryngoscopic view. My personal experience with use of the flange-padded laryngoscope blade revealed ease of use and function in a wide range of airways that underwent direct laryngoscopy. Furthermore, the amount of time preparing the