Robert S. Lagasse

Anesthesia Safety: Model or Myth?A Review of the Published Literature and Analysis of Current Original Data

Anesthesia Safety: Model or Myth?: A Review of the Published Literature and Analysis of Current Original Data Robert Lagasse; Anesthesiology

Factors influencing the reporting of adverse perioperative outcomes to a quality management program.

Quality management programs have used several data reporting sources to identify adverse perioperative outcomes. We compared reporting sources and identified factors that might improve data capture. Adverse perioperative outcomes between January 1, 1992, and December 31, 1994, were reported to the Department of Anesthesiology Quality Management program by anesthesiologists, hospital chart reviewers, and other hospital personnel using incident reports. The reports were compared for preoperative health status, severity of outcome, and associated human error. Subsequently, personnel representing the various sources were surveyed regarding factors that might affect their reporting of adverse outcomes. Of 37,924 anesthetics, 734 (1.9%) adverse outcomes were reported, 519 (71%) of which were identified by anesthesiologists, 282 (38%) by chart reviewers, and 67 (9.1%) by incident report. There was no statistically significant difference in reporting rates by anesthesiologists according to preexisting disease, severity of outcome, or presence of human error. Thirteen cases involving human error, however, resulted in disabling patient injury, with a higher rate of self-reporting for these cases (92%, P < 0.05). Rates of reporting by chart reviewers varied (P < 0.05) according to severity of patient illness and severity of outcome. Incident reports identified only 67 adverse outcomes (9.1%), but included a significantly higher percentage of the adverse outcomes involving human error (23.3%, P < 0.05). Twenty attending anesthesiologists, 15 resident anesthesiologists, 29 operating room nurses, 19 postanesthesia care unit nurses, and 6 hospital chart reviewers responded to the survey. Only the potential to improve quality of patient care influenced or strongly influenced a decision by all groups to report an adverse outcome to a peer review process. Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Implications Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Reporting by chart reviewers is biased both by the severity of outcome and severity of patient illness, whereas incident reports tend to focus on human error. All groups feel compelled to report adverse outcomes when the data may result in improved patient care.

relationship between Malpractice Litigation and Human Errors

IN medical malpractice litigation, negligence is the predominant theory of liability. The basic elements of a malpractice claim are duty, negligence, causation, and damage. Duty refers to the practitioners responsibility to treat a patient according to the standard of care. Negligence is defined by law as a deviation from the accepted standard of care and, therefore, a breach of duty. Causation requires that the patient’s damage is the result of negligence, and damage infers harm, detriment, or loss sustained by reason of an injury. Much of our current knowledge of medical malpractice comes from the Anesthesia Closed Claims Database, which was established in 1985 by the American Society of Anesthesiologists and is based on a limited number of reviews of closed malpractice claims. These retrospective reviews suggest that a malpractice claim can result in a financial award even in the absence of negligent care. Conspicuously missing from these reviews, however, are uncompensated patients whose injuries were the result of deviations from the standard of care that did not result in closed claims. Without this information, the true relation between injury caused by human error and malpractice claims cannot be determined. In this investigation at a university hospital, cases involving legal action against anesthesia providers were compared to deviations from the standard of care by anesthesia providers that resulted in disabling patient injuries as judged by peer review to determine the relation between these two occurrences.

Prolonged Neuromuscular Blockade Following Vecuronium Infusion

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

Application of the Grieshaber® air system to maintain endotracheal tube cuff pressure

The Grieshaber Air System was designed to maintain intraocular pressure during ophthalmologic surgery. It also has been used to maintain pressure in leaking endotracheal tube cuffs. It is a very useful device, especially if the intubation is difficult or the patients position precludes replacement of the endotracheal tube. Two patients are presented in whom the system was used to maintain endotracheal tube cuff pressure.

National performance data registries: preparing for the perfect storm.

I N October 1991, a series of mundane weather fronts combined in the Maritimes southeast of Nova Scotia to form a monstrous anomaly that the National Weather Service termed the “perfect storm.” In 2000, The Perfect Storm, a movie adaptation of Sebastian Junger’s book of the same name, chronicled the perilous course of the swordfishing boat Andrea Gail as it unrealistically chose to challenge this perfect storm in an attempt to avoid devastating financial losses. The term “perfect storm” is now defined by Merriam-Webster’s dictionary as a critical or disastrous situation created by a powerful concurrence of factors.* Partial successes, costly data collection, inadequate risk adjustment, and a failing healthcare system represent some of the concurrent factors leading to a perfect storm of centralized performance data registries. Like the crew of the Andrea Gail, anesthesiologists are being forced to sail into this storm to avoid financial losses. The Veterans’ Administration (VA) National Surgical Quality Improvement Project (NSQIP) developed and validated separate risk adjustment models for 30-day morbidity and 30-day mortality after major surgery in eight surgical subspecialties and for all operations combined. In the VA NSQIP’s first 10 yr, the 30-day postoperative mortality for major surgery decreased from 3.1% to 2.2%. Even more dramatically, the number of patients undergoing major surgery who experienced 1 or more of 20 predefined postoperative complications decreased from 17.8% to 9.8%, whereas the median length of stay declined by 5 days. With this obvious success, the American College of Surgeons moved NSQIP into the private sector with the hope that similar success in non-VA hospitals would give it market value and make it a worthwhile investment for hospitals. Unfortunately, the science and technology for health outcomes data collection and risk adjustment are primitive, and the costs of both remain high. In the VA NSQIP, the cost of manual data collection and off-site data analysis has been quoted at approximately

The Right Stuff: Veterans Affairs National Surgical Quality Improvement Project

38 per case. The VA expands its database by approximately 100,000 cases per year, so their first 10-yr cost was approximately

Defining Quality of Perioperative Care by Statistical Process Control of Adverse Outcomes

38 million. The reduction in morbidity and mortality within the VA system may have justified this initial cost, but it is unclear whether continued costs can be justified. The VA network has shown little improvement in morbidity and mortality lately, and the costs remain the same. Compared with 15 academic centers in the private sector, the VA showed comparable morbidity and mortality rates, but that was after the VA had maximized their improvement. Unlike VA NSQIP, the American College of Surgeons NSQIP is made up of individually participating hospitals, each looking for its own return on investment; but the bestperforming hospitals may be unable to justify the costs of participation. Similarly, despite initial successes, the AmeriImage: ©istockphoto.com.

To See or Not to See

Robert S. Lagasse, MD*† The 1983 movie, The Right Stuff, was an adaptation of Tom Wolfe’s book by the same name that chronicled the Project Mercury astronauts selected by the National Aeronautics and Space Administration (NASA). Project Mercury began in 1959 and was the first manned space flight program in the United States (US). At that time, the Soviet Union was clearly leading the way in rocket technology and the US was not “measuring up.” The political mandate of competing against the Soviet Union in the “space race” seemed doomed to failure given the expense of such an endeavor and our obvious technology deficits. The first human space flight occurred on April 12, 1961, when cosmonaut Yuri Gagarin orbited the earth aboard a Soviet spacecraft. Fortunately, a determined group of astronauts, dubbed the Mercury Seven, brought the “right stuff” to the NASA program and the United States became the second nation to achieve manned space flight with the suborbital flight of astronaut Alan Shepard on May 5, 1961. Less than 1 yr later, the first US orbital flight was achieved by John Glenn, and established the US as a true competitor in space. As of this year, human spaceflight missions have been conducted by the Soviet Union, the US, Russia, the People’s Republic of China, and by a private US space flight company. I mention this brief history of the early years of the Project Mercury space program because I believe there are many parallels between the NASA quest for manned space flight and the Department of Veterans Affairs (VA) quest for quality perioperative care as described by Bishop et al. in this issue of Anesthesia & Analgesia. During the mid-to-late 1980s, the VA came under a great deal of public scrutiny over the quality of surgical care in their 133 hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that the VA was not measuring up to the private sector. To address the gap, Congress mandated the VA to report risk-adjusted surgical outcomes annually, and compare their outcomes to national averages. Unfortunately, perioperative performance measurement technology had not advanced to the point where there were risk-adjusted national averages. Still, the VA was able to exhibit the right stuff and develop the National Surgical Quality Improvement Program (NSQIP) that includes risk adjustment models for 30-day morbidity and mortality after major surgery in 8 surgical subspecialties and for all operations combined. Preoperative patient characteristics used in these models include demographics, symptoms, physical findings, comorbidities unrelated to the reason for surgery, preoperative laboratory values, and ASA physical status which, with all of its strengths and weaknesses, is a major predictive factor. But, this modeling did not come without a price. The cost of data collection and analysis has been quoted at approximately

Factors influencing hospital implementation of acute pain management practice guidelines

38 per case. The VA database is expanding by approximately 100,000 cases annually and currently has more than 1 million cases. Thus, the cost to date has been more than