Obstetrical deaths in the UK--Anesthesia component
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Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom
Chapter 9--Anaesthesia
The anesthesia chapter concludes:
"The management of haemorrhage is a shared responsibility of midwifery, obstetric, anaesthetic and blood transfusion personnel. Anaesthetists should be ready to suggest that the obstetrician summons help in the face of major haemorrhage regardless of the obstetrician’s grade or experience. Good communication is vital and regular practice of emergency drills is crucial, particularly in units with a high turnover of staff."
I would like to think that many of the problems pointed out in this report would not happen in the United States, but that would be intellectually dishonest. If you provide anesthesia for obstetrical patients as I do, it's worth reading over this report for the lessons that are applicable in the US.
Senate Committee Approves Bill To Establish Medical Error Reporting Database
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Kaisernetwork.org--Capitol Hill Watch | Senate Committee Approves Bill To Establish Medical Error Reporting Database - :
" The Senate Health, Education, Labor and Pension Committee on Wednesday approved by voice vote a bill (S 544) that would create a database to allow care providers to report medical errors, CQ Today reports. The database would be used to track medical errors, examine trends and prevent reoccurring mistakes, CQ Today reports. Information included in the database would not be used in medical malpractice lawsuits, according to CQ Today. Before the full Senate considers the measure, committee Chair Michael Enzi (R-Wyo.) and Sen. Edward Kennedy (D-Mass.) are expected to insert language to clarify that the bill would not affect information already available to attorneys for use in malpractice suits. The committee last year approved similar legislation, which was unanimously approved by the Senate. The House approved a separate version of the legislation, but the issue died after conference committee members were not appointed. The new bill is expected to pass the Senate. The House Energy and Commerce Committee has not yet scheduled a review of the bill (Schuler, CQ Today, 3/9). "
'X' Marks the Spot. Or Does It?
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Newsday.com has details of a recently announced jury verdict in a case of wrong side surgery:
" "A Manhattan hospital and the chief doctor for the New York Rangers hockey team were ordered Thursday to pay a dance director and choreographer a total of $450,000 because the physician operated on the man's wrong knee.
The jury awarded the money to Douglas Hall, 43, who entered St. Vincent's Hospital on Nov. 30, 2001, for arthroscopic surgery on his right knee. Despite marking that knee with an 'X,' Dr. Andrew Feldman operated on the left knee. " "
Does an 'X' mean 'operate on this one' or does it mean 'do not operate on this one--operate on the other one'? I've seen a few patients write 'No!' on the non-operative side. We all got a chuckle out of it, but it worked! Rather than an 'X', the mark should be placed on and refer to the correct side--either 'R' or 'L'.
The rest of the article points out that the OR was also set up for the wrong side. Just another example of multiple failures being needed for a medical misadventure to occur. I'm sure there was no end of the 'blame game' going on for this one.
Anatomy of a Near Miss
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Medical errors are insidious. Many, many errors occur that do not lead to a bad outcome, but they are errors nonetheless. Given a different patient or set of circumstances, those same errors could result in injury, death, or at the very least less than optimal care. The following example serves to reinforce this point.
A thin, elderly woman is admitted the morning of her planned multi-level spinal laminectomy, instrumentation, and fusion. She is healthy, active, and appears younger than her stated age. She meets her anesthesiologist for the first time twenty minutes before the case. Upon review of her records, she appears to be free of cardia or pulmonary disease, but he notes laboratory results on the chart which indicate a macrocytic anemia (blood count of 30--normal is greater than 35 or so). The patient does not recall being told this before. No mention is made of this finding in the surgeon's history and physical examination, or elsewhere in the chart. Someone did think to do serum B12 and folate levels, both of which were found to be normal but no note is present to indicate the differential or planned workup. The finding is discussed with the surgeon and the case proceeds.
Error number one: the abnormal laboratory value should have triggered further evaluation. Some evaluation was attempted, but there was nothing in the chart to indicate by whome, or what their conclusion was. Significant blood loss is likely in this case. Starting with a lower hematocrit means less blood can be lost before a transfusion becomes necessary.
Error number two: the anesthesiologist should have cancelled this case due to a new anemia of unknown etiology. The severity of the anemia is such that a blood transfusion will almost certainly be needed. If time had been taken to evaluate and treat the anemia, the blood count may have risen sufficiently to reduce the likelihood of needing a transfusion. Even if the blood count could not be improved, directed donation or intraopoerative blood salvage techniques could have been used. Why didn't the anesthesiologist cancel the case? No good reasons, just all the usual ones. He was afraid the surgeon would be angry. He kne w the patient had been dealing with severe pain and was holding out just for this surgery.
Intra-operative blood loss was approximately 700 cc. Euvolemia was maintained with Hespan and lactated Ringer's solution. The patient was warm, urine output was good, and both blood pressure and heart rate were stable. Her hemoglobin near the end of the case was now 7, and a unit of blood was ordered from the blood bank. When no blood arrived within 30 minutes, the blood bank was called to inquire if there was a problem. No blood sample from the patient was available in the blood bank to cross-match bank blood against. A sample was immediately drawn into a red-top vial and sent. The case ends, patient is extubated successfully, and transported to the recovery room where her vital signs remain stable and urine output good. The anesthesiologist continues with other scheduled cases after giving report and asking the recovery room nurse to administer one unit of blood when it become available.
After another thirty minutes pass, the blood bank calls the recovery room to inform them that the sample was received in the wrong vial. The blood bank used to require a red-topped vial, but now want a lavender-topped vile (the former contains no anticoagulant, the later does). A phlebotomist is called to draw the new sample and the patient received a blood transfusion fully two hours after the anesthesiologist made the decision to administer blood.
Error numbers three through ten: 'what we have here is a failure to communicate.' There was a failure to communicate:
- that blood had not been drawn pre-operatively as ordered (even though the pre-op checklist indicated it had)
As an interesting aside, this was the first morning the nurses in the pre-op area were asked to use a computerized nursing record rather than their preferred paper method of charting.
- that the blood bank had no specimen to crossmatch blood against after receiving a call for blood.
- that a change had been made in what kind of specimen was needed for crossmatch.
- you can fill in the remainder.
The only reason this patient did not suffer harm from this incident is that she was physiologically very healthy. Imagine a patient with stable but significant coronary disease. That patient would not have tolerated a hemoglobin of seven so well. Imagine a more significant blood loss. It's better to be lucky than good. It's even better to be both.
This example demonstrates what is so often true of medical misadventures: it is a series of events
in combination which conspire against the practitioner and the patient to cause harm.
My response to this event is to draft a 'Go/No-Go' list. My personal decisions on whether to do a case is heavily influenced by what I know the surgeon reaction will be. I'm not saying that's the right reaction, mind you. It's just my reaction (in wanting to please people as I do). A Go/No-Go list is similar to what NASA uses to decide whether or not to launch a space craft. If any item is 'No-Go' the launch is scrubbed. On my anesthesia Go/No-Go list, if I discover an item in a patient chart that's on my list, launch is scrubbed and the case is rescheduled. New, unexplained anemia is certainly on that list, especially in light of a surgery likely to result in significant blood loss. I need to spend some serious time adding to this list. I'll post it as a work in progress.
