AM RAY ORATION

Slide 1: 

Good afternoon to all of you. Respected Chair persons & co-chair person first of all I extend my deep gratitude to the organisers for having invited me to deliver this Dr AM Ray memorial oration in this historical city of temples. The subject that I have chosen for my oration is related to an honest confession that every human being commits mistakes and Anaesthesiologists are no exception. No matter how expert one may be but errors do happen & it is better to share them rather than putting them under the carpet.

To err is human, To share is divine : 

To err is human, To share is divine Dr.S.S.Rathaur CMS-Ahmedabad-WR

A Case of faulty equipment : 

A Case of faulty equipment Female child 10 yrs. 16 Kg. ASA-I status for Tonsillectomy on 13-6-98 in the same OT, with mark-F Boyle machine & Fluotec -II vaporiser

Slide 4: 

PAC Hb= 11gms% BT,CT=WNL X-ray Chest= BVM+ Pre-op BP=100/60 mmHg PR=108/min.

Induction of Anaesthesia : 

Induction of Anaesthesia Pre-oxy. 5 min.(1130 hrs) Inj.Pentothal(2.5%) = 80 mg + Inj.Atropine=0.3 mg + Inj.Succinylcholine =50 mg + IPPV Orotracheal plain RR ETT 4.5

Maintenance : 

Maintenance N2O (50%)+ O2(50%) + Halothane 0.5 - 1% with Assisted Resp. using JR modification of Ayre’s T piece as spontan.resp.did’t resume after Succinylcholine

Monitoring : 

Monitoring Precordial stethoscope auscultation BP & Pulse by trained S/nurse every 5 min. as there was no monitor available

Recovery : 

Recovery Tonsillectomy over at 1250 hrs Halothane switched off &100% O2 on After 10 min- Not responding to either Verbal or Painful stimuli - No response to Carinal stimulation - Pupils semi dilated ,not reacting

Slide 9: 

After 30 min.-No resp.efforts -BP started falling - Non responsive - Pupils dilated ,non reactive After 40 min.-BP unrecordable but Heart sounds & Carotid pulsations present

Slide 10: 

Inj.Mephentine 7.5 mg I.V. repeated every 5 min. for 3 doses without response Inj.Dopamine @ 10 ugm /kg/min started Inj.soda-bicarb(7.5%) 5 ml Inj.Hydrocortisone 50 mg I.V. BUT BP STILL UNRECORDABLE

Slide 11: 

After 50 min.-Noticed that Fluotec vaporiser was empty(Filled 1 hr. back) SUSPECTING A FAULTY VAPORISER Boyle machine was changed & 100% O2 given

Slide 12: 

Within 10 min.of changing the machine (At 1350 hrs) -Spontan.resp.resumed -BP was 90 mmHg systolic - PR was 140/min. regular - Pupils started reacting -Moving limbs At 1410 hrs.-extubated - O2 with mask contd.

Slide 13: 

At 1420 hrs- - Fully conscious -Responding to verbal commands -BP 90 mmHg syst. -PR 120/min ,regular - Pupils NSR - Breathing spontaneously At 1435 hrs- Shifted to P.O.ward

Slide 14: 

FLuotec mark -II vaporiser used in this case was checked by me after re-filling with Halothane & it was found THAT HALOTHANE LEAKED INTO THE MAGILL’S CIRCUIT EVEN IN OFF POSITION WHILE USING ONLY 100% OXYGEN IT WAS CONFIRMED BY SNIFFING BY 3 DIFFERENT WORKERS IN THE OT

Anaesthesiology is not a child’s game? : 

Anaesthesiology is not a child’s game?

High Risk Organisations : 

High Risk Organisations Hazardous but very low accident rate Commercial aviation War ships Nuclear power plants

Key Principles of safety-in HRO : 

Key Principles of safety-in HRO Powerful & uniform culture of safety- Motto is that consciously unsafe acts should not occur. Use of optimal structures & procedures Intensive & continuous training of staff individually & as teams

Progress of anaesthesia : 

Progress of anaesthesia 1846-WTG Morton Modern OT today 162 years Anaesth. Work station Anaesth bag

Slide 20: 

The underwater Aquarius lab in Florida, hosting a gall bladder removal surgery on a  dummy as a test for eventual remote surgery in space via the robotic system. Eventually astronauts in need of surgery won't have to come back to Earth. The Future is bright

Slide 21: 

WHY TALK OF SAFE ANAESTHESIA

Slide 22: 

All anaesthetic drugs and techniques can cause death Anaesthesia in itself does not offer cure Fast growing public awareness Demanding accountability Paucity of resources not acceptable It is high time we wake up FIRST OF ALL DO NO HARM

Slide 23: 

THE PROBLEM ? QUANTUM OF PROBLEM POSSIBLE SOLUTIONS

THE PROBLEM ? : 

THE PROBLEM ? ERRORS IN ANAESTHESIA RESULT IN MORBIDITY & MORTALITY

PROBLEM? : 

PROBLEM? CAUSES OF ERRORS IN ANAESTHESIA HUMAN FAILURES EQUIPMENT FAILURES MIX OF BOTH

Slide 26: 

Medication is the leading cause of adverse events in anesthesia Efforts to improve drug safety must be coordinated at national and international levels.

PRE-ANAESTHETIC CHECK : 

PRE-ANAESTHETIC CHECK No documentation No proper format –missing important inform No proper investigations No proper drug history / past Anaesth history Examination by juniors only ! Too tired to conduct PAC ! Failure to communicate with the patient Language barrier ! Causes of anaesthesia errors!

PRE-OPERATIVE PERIOD : 

PRE-OPERATIVE PERIOD FAILURE TO ENSURE IDENTITY OF PATIENT FAILURE TO CHECK PART TO BE OPERATED FAILURE TO TAKE PROPER INFORMED CONSENT FAILURE TO PRE CHECK MACHINE & VAPORISERS FAILURE TO PRE CHECK PATIENT’S PARAMETERS FAILURE TO PRE CHECK INJECTIONS TRAY / CRASH CART FAILURE TO PRE CHECK LARYINGOSCOPE & ETT FAILURE TO PRE CHECK CYLINDERS FAILURE TO CHECK SUCTION MACHINE FAILURE TO KEEP DIFFICULT INTUBATION TROLLY READY LACK OF PROPER ASSISTANCE BY TRAINED PARAMEDICS WORKING WITH A NEW MACHINE / NEW OT / NEW SURGEON POWER FAILURE WITH NO BACK UP CAUSES PRIOR TO INDUCTION

INTRA-OP PERIOD : 

INTRA-OP PERIOD CAUSES DURING INDUCTION USING UN LABELLED SYRINGES / AMPOULES SYRINGE SWAP / AMPOULE SWAP POOR OR NO ASSISTANCE BY PARAMEDICS –shortage SINGLE ANAESTHETIST –APPREHENSIVE / LACK OF CONFIDENCE / OVERCONFIDENCE POOR PLANNING ! POORLY MAINTAINED ANAESTH. MACHINE FAILURE OF LARYNGOSCOPE-POOR / NO LIGHT IMPROPER SELECTION OF ETT WRONGLY FILLED OXYGEN / N2O CYLINDERS ! NOT FOLLOWING MANDATORY MONITORING STANDARDS ODD HOURS / FATIGUED ANAESTHETIST COMPELLED TO FINISH LIST

INTRA-OP PERIOD : 

INTRA-OP PERIOD CAUSES DURING MAINTENANCE FAILURE TO CHECK MONITORS / SILENT THE DEFAULT ALARMS ! FAILURE TO MAINTAIN CONTACT WITH PATIENT POOR ANALGESIA UNDER GA TOO LIGHT / TOO DEEP ANAESTHESIA SHARED AIRWAY –ENT SURGERY ODD SURGICAL POSTIONS LEAVING THE TABLE DURING OPERATION ! ATTENDING >ONE PATIENT AT A TIME POOR SURGICAL SKILLS ! ALLERYGY TO ANTIBIOTICS USED INTRAOP SURGEONS KEEP CHANGING BUT ANAESTHETIST SAME !

POST-OP PERIOD : 

POST-OP PERIOD CAUSES DURING EMERGENCE INCOMPLETE REVERSAL PRE MATURE EXTUBATION -ASPIRATION HEMODYNAMIC INSTABILITY POOR OXYGENATION NO PACU ! NO PROPER HANDING OVER OF PATIENT NO MONITORING DURING SHIFTING PREMATURE SHIFTING TO WARD ! NO ANAESTHETIST IN POST OP WARD / ICU

QUANTUM OF PROBLEM ? : 

QUANTUM OF PROBLEM ? Exact no. of anaesthesia errors is impossible to predict due to poor reporting systems even in the West. Current statistics indicate that 1 in every 200,000 to 300,000 patients die due to anesthesia related complications.

Slide 34: 

a review of 896 reports Anaesthesia, Volume 60, Number 3, March 2005 , pp. 220-227(8)

The Australian Incident Monitoring Study. : 

The Australian Incident Monitoring Study. Amongst the first 2000 incidents reported to the Australian Incident Monitoring Study, there were 144 incidents in which the "wrong drug" was nearly or actually administered to a patient. in over half of such cases the syringes were of the same size, and also, in over half, they were correctly labelled. In 81% of the 144 incidents the "wrong drug" was actually given. This was more common with syringes (93%) than ampoules (58%). Thus the most common error was actually giving the wrong drug from a correctly labelled syringe. The most common drug involved was a muscle relaxant in both ampoule and syringe incidents. In 74% of all reports, there was the potential for serious harm to the patient; however no deaths were reported. Currie M, Mackay P, Morgan C, Runciman WB, Russell WJ, Sellen A, Webb RK, Williamson JA.

The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. : 

The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Factors which contributed significantly to the incidents were similar appearance, inattention and haste. "Failure of communication" was a significant factor in syringe incidents when two or more staff were involved. The only significant factor which minimized the outcome was rechecking of the syringe or drug ampoule before giving the drug. MID: 8273881 [PubMed - indexed for MEDLINE]

MORTALITY IN ANAESTHESIA : 

MORTALITY IN ANAESTHESIA Three decades ago, a healthy patient undergoing general anaesthesia had an estimated 1 in 5000 chance of dying from complications of anaesthesia (20). With improved knowledge and basic standards of care, the risk has dropped to 1 in 200 000 in the industrialized world—a 40-fold improvement. Unfortunately, the rate of avoidable death associated with anaesthesia in developing countries is 100–1000 times this rate. Published series showing avoidable anaesthesia mortality rates of 1:3000 in Zimbabwe 1:1900 in Zambia 1:500 in Malawi 1:150 in Togo demonstrate a serious, sustained absence of safe anaesthesia for surgery.

Slide 38: 

WHAT IS THE SOLUTION?

Slide 39: 

1.SURGICAL SAFETY CHECK LIST-WHO 2.DRUG LABELLING 3.COLOUR CODING OF DRUGS 4.AUTOMATION 5.QUALIFIED ANAESTHESIOLOGIST 6.MANDATORY MINIMUM MONITORING SPO2 & ETCO2 7.VOLUNTARY REPORTING OF ERRORS 8.CHANGING ORGANISATIONAL CULTURE

1.SURGICAL SAFETY CHECK LIST : 

1.SURGICAL SAFETY CHECK LIST “Safe Surgery Saves Lives“ WHO campaign supported by 284 Organisations including WFSA to make surgical experience completely safe and error free in operating rooms worldwide. A check list has been issued by WHO http://www.who.int/patientsafety/safesurgery/tools_resources/ SSSL_Checklist_finalJun08.pdf

WHO-SURGICAL SAFETY CHECKLIST : 

WHO-SURGICAL SAFETY CHECKLIST BEFORE INDUCTION OF ANAESTHESIA- SIGN IN PATIENT HAS CONFIRMED • IDENTITY • SITE • PROCEDURE • CONSENT SITE MARKED/NOT APPLICABLE ANAESTHESIA SAFETY CHECK COMPLETED PULSE OXIMETER ON PATIENT AND FUNCTIONING DOES PATIENT HAVE A: KNOWN ALLERGY? NO YES DIFFICULT AIRWAY/ASPIRATION RISK? NO YES, AND EQUIPMENT/ASSISTANCE AVAILABLE RISK OF >500ML BLOOD LOSS (7ML/KG IN CHILDREN)? NO YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED

BEFORE SKIN INCISION : 

BEFORE SKIN INCISION CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM • PATIENT • SITE • PROCEDURE ANTICIPATED CRITICAL EVENTS SURGEON REVIEWS: WHAT ARE THE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED BLOOD LOSS? ANAESTHESIA TEAM REVIEWS: ARE THERE ANY PATIENT-SPECIFIC CONCERNS? NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR ANY CONCERNS? HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES? YES NOT APPLICABLE IS ESSENTIAL IMAGING DISPLAYED? YES NOT APPLICABLE TIME OUT

BEFORE PATIENT LEAVES OT : 

BEFORE PATIENT LEAVES OT NURSE VERBALLY CONFIRMS WITH THE TEAM: THE NAME OF THE PROCEDURE RECORDED THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT APPLICABLE) HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME) WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED _________________________________________________ SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED SIGN OUT

2-DRUG LABELLING : 

2-DRUG LABELLING "Whenever possible, each drug available on the anaesthetic cart should have distinct and unique markings." Canadian Standards Association (CSA) #Z327-M91 Standard for User Applied Drug Labels in Anaesthesia and Critical Care is similar to the American Standards for Testing and Materials (ASTM) D4774-93.5

DRUG LABELLING IS SIMPLEST : 

DRUG LABELLING IS SIMPLEST Development of unambiguous drug labels that are easy to read and designed primarily for safety rather than marketing is an important starting point

Slide 46: 

Merry, A. F. et al. Anesth Analg 2001;93:385-390 Labels for the system prefilled syringe label, ampoule flag label top of label sheet

Slide 47: 

Merry, A. F. et al. Anesth Analg 2001;93:385-390 Trays facilitate orderly arrangement of syringes and ampules, to provide a physical means by which drugs used during an anesthetic may be tracked SYRINGE TRAY

Slide 48: 

If the wrong drug is drawn up previously labelled syringe, a disaster could result.

Slide 49: 

safest way to avoid these mishaps is to meticulously read the contents of an ampoule/vial.

How Should We Administer Drugs? : 

How Should We Administer Drugs? 1. Syringes should be labelled 2. Legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards 3. The label on any drug should be carefully read before a drug is drawn up or injected. .

Slide 51: 

4. Formal organization of the drug drawers and workspace -position of ampoules and syringes, -separation of similar or dangerous drugs, -removal of dangerous drugs from the OT 5. The use of devices at the point of care to automatically measure the dose of drug administered.

Standardise syringe sizes : 

Standardise syringe sizes Standardise syringe sizes for particular drugs. Always use dedicated 5 ml syringes for all muscle relaxants. 10 ml syringes are suggested for opiates 20 ml for intravenous anaesthetic agents. However, this recommendation may not always be applicable for Paediatric patients.

“Pre-labelled syringes?” : 

“Pre-labelled syringes?” DON’T USE PRE-LABELLED SYRINGES BETTER LABEL AFTER FILLING THE DRUG

3-COLOUR CODING : 

3-COLOUR CODING Colour coding is used in anesthesia for cylinders, pipelines, flow meters, vaporizers, lines and syringe stickers because it adds to the safety. Why shouldn't labelling of ampoules also be colour coded?

4-AUTOMATION : 

4-AUTOMATION Is it fool-proof? Today , automation has increased tremendously in aviation and medicine. Unfortunately , when the automation is reliable most of the time , one starts to trust it completely , become complacent , and stop monitoring its function. When the automation fails disaster strikes. It is important when using automation to understand its limitations & monitor its functioning.

INTEGRATED DRUG ADMINISTRATION SYSTEM(IDAS) : 

INTEGRATED DRUG ADMINISTRATION SYSTEM(IDAS) Several hospitals in Auckland are using IDAS to support the administration of anaesthetic drugs during operations. The system has been designed based on first principles of patient safety. It provides procedures and tools for keeping the anaesthetic work area organised, for confirming drugs before administration, and keeping a record of drugs administered.

Slide 57: 

3. The use of a bar-code reader to scan the drug at the point of administration immediately before it is given, linked to an auditory prompt (i.e., the computer speaks the name of the scanned drug) and a visual prompt (i.e., the computer displays the name of the drug, in prominent color-coded format) to facilitate checking of the drug's identity. 4. Integration of scanned information into an automated anesthetic record, facilitating accuracy of the drug information in the record Merry, A. F. et al. Anesth Analg 2001;93:385-390 BAR CODE READERS

5-QUALIFIED ANAESTHESIOLOGIST : 

5-QUALIFIED ANAESTHESIOLOGIST Medical science is always producing more sophisticated equipment in making procedures safer, easier, and less stressful on the patient. However, they are far from foolproof and a qualified anesthesiologist is always needed to observe and avoid anesthesia error.

Man behind the machine ! : 

Man behind the machine ! The operator must still do things that cannot be automated. to monitor automated systems for rare, abnormal events because machines cannot deal with infrequent events in a constantly changing environment. Fortunately, automated systems rarely fail. Unfortunately, this means that operators do not practice basic skills, so workers lose skills in exactly the activities they need in order to take over when something goes wrong.

6-MANDATORY MONITORING : 

6-MANDATORY MONITORING Pulse oximetry & Capnography are LIFE SAVING INNOVATIONS which helps doctors determine at a glance that a patient is breathing properly. By 1990, almost all American hospitals had pulse oximeters and capnographs

Slide 61: 

234 million surgical operations a year In developed countries 100% OT’s have Pulsoximeters whereas in 1,20,000 low income OT’s 50-90% do not have

Slide 62: 

Engineering innovations have virtually eliminated problems with the delivery of oxygen to patients. A recent review of 4,000 incidents and over 1,200 medico-legal notifications reported by anesthetists in Australia revealed no cases of hypoxic brain damage or death from inadequate ventilation or misplaced tubes since the introduction of oximetry and Capnography. However, no such systematic innovations have yet been widely adopted to reduce medication error.

7-REPORTING OF ERRORS : 

7-REPORTING OF ERRORS The establishment of a voluntary reporting program for anesthesia-related adverse events Currently, in Canada drug errors or near-misses can be reported to the Institute of Safe Medication Practices Canada (www.ismp-canada.org). Protection from litigation for the reporter must be enacted in all provinces if adverse event reporting programs are to succeed.

Error Reporting Systems : 

Error Reporting Systems "voluntary reporting systems.“ -focus on safety improvement "mandatory reporting systems.“ -to hold providers accountable

Understanding Errors : 

Understanding Errors The work of Reason provides a good understanding of errors. He says- Errors depend on two kinds of failure, “either actions do not go as intended or the intended action is not the correct one.” In the first case, the desired outcome may or may not be achieved; in the second case, the desired outcome cannot be achieved.

A standardized reporting format is needed : 

A standardized reporting format is needed For either type of reporting program, implementation without adequate resources for analysis and follow-up will not be useful. Receiving reports is only the first step in the process of reducing errors. Sufficient attention must be devoted to analyzing and understanding the causes of errors in order to make improvements.

A standardized reporting format is needed : 

A standardized reporting format is needed Being able to conduct good analyses also requires that the information received through reporting systems is adequate. People involved in the operation of reporting systems believe it is better to have good information on fewer cases than poor information on many cases. The perceived value of reports lies in the narrative that describes the event and the circumstances under which it occurred. Inadequate information provides no benefit to the reporter or the health system.

Why did “The Challenger “fail ? : 

Why did “The Challenger “fail ? because of a combination of brittle O-ring seals, unexpected cold weather, reliance on the seals in the design of the boosters, and change in the roles of the contractor and NASA. Individually, no one factor caused the event, but when they came together, disaster struck. We lost Kalpana Chavla

Latent and Active Errors : 

Latent and Active Errors Active errors - sharp end occur at the level of the frontline operator, and their effects are felt almost immediately. The active error is that the pilot crashed the plane. Latent errors - blunt end are not under direct control of the operator and include things such as poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations. The latent error is that a previously undiscovered design malfunction caused the plane to roll unexpectedly in a way the pilot could not control and the plane crashed. Discovering and fixing latent failures and decreasing their duration are likely to have a greater effect on building safer systems than efforts to minimize active errors at the point at which they occur.

8-CHANGING ORGANISATIONAL CULTURE : 

8-CHANGING ORGANISATIONAL CULTURE It is impossible to address drug error effectively without addressing the organizational culture of anesthesia. A blame free culture – James Reason in Human errors. Today most authorities (including Reason) advocate a "Just Culture." i.e. early triage of incidents into those in which blame may be appropriate, and those in which it is not. leaving an anesthetized patient unattended, or working under the influence of alcohol or drugs.

Why Do Errors Happen? : 

Why Do Errors Happen? People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; The problem is that the system needs to be made safer.

What is safety? : 

What is safety? “safety is defined as freedom from accidental injury” Safety does not reside in a person, device or department, but emerges from the interactions of components of a system

"Madness is doing the same thing over and over again and expecting a different result." -Einstein : 

"Madness is doing the same thing over and over again and expecting a different result." -Einstein We will not reduce drug error until we change the way we give drugs.

How to eliminate human errors? : 

How to eliminate human errors? The occurrence of human error creates the perception that humans are unreliable and inefficient. One response to this to find the unreliable person who committed the error and focus on preventing him or her from doing it again. Another response to increase the use of technology to automate processes so as to remove opportunities for humans to make errors.

Implement proven medication safety practices. : 

Implement proven medication safety practices. Reducing reliance on memory; Simplification; Standardization; Use of constraints and forcing functions; The wise use of protocols and checklists; Decreasing reliance on vigilance, handoffs, and multiple data entry; and Differentiating among products to eliminate look-alike and sound-alike products.

Slide 76: 

building in redundancy, developing backup systems, organizational design team performance. need to have the right equipment, well-maintained and reliable; a skilled and knowledgeable workforce; reasonable work schedules, well-designed jobs; clear guidance on desired and undesired performance, etc.

INDIVIDUAL VS SYSTEM CORRECTION : 

INDIVIDUAL VS SYSTEM CORRECTION Current responses to errors tend to focus on the active errors by punishing individuals (e.g., firing or suing them), retraining or other responses aimed at preventing recurrence of the active error. Although a punitive response may be appropriate in some cases, it is not an effective way to prevent recurrence. Since the same mix of factors is unlikely to occur again, efforts to prevent specific active errors are not likely to make the system any safer.

Slide 78: 

human + technology is more powerful than either alone

How Other Industries Have Become Safer : 

How Other Industries Have Become Safer The risk of dying in a domestic jet flight between 1967 and 1976 was 1 in 2 million. By the 1990s, the risk had declined to 1 in 8 million. Health care is decades behind other industries in terms of creating safer systems We have much to learn from other industries about improving safety

Relative Risk of Anesthesia Compared to Air Travel : 

Relative Risk of Anesthesia Compared to Air Travel Assuming a death risk of 1 in 10 million for commercial aviation and assuming an average of 2 hours per domestic flight, the death risk would be about 5 per 100 million hours of exposure. If we assume a preventable anesthetic mortality of 1 in 100,000 and assuming the average anesthetic to last about 2 hours, the anesthesia death risk would be 500 per 100 million hours of exposure. i.e. 100 times risky than aviation! Fact is that anesthesia is far less safe than flying as a passenger with one of the big commercial airline companies.

Anaesthesia vs Aviation : 

Anaesthesia vs Aviation The biggest single difference between anesthesia and aviation relates to the perception that expenditure on safety is justified. The numbers involved in a single airline accident grab public attention and demand a response. Individual anesthesiologists harm patients 1 at a time. It being sporadic is largely invisible. Imagine the public's response to 5,000 plus cases of intraoperative awareness if they all occurred in 1 hospital in the first 2 weeks of January, instead of being spread out over the calendar year and the entire country.

"To err is human; to cover up is unforgivable; to fail to learn is inexcusable." : 

"To err is human; to cover up is unforgivable; to fail to learn is inexcusable."

Slide 83: 

The importance of an adverse event should be judged by its potential outcome rather than its actual outcome.

Why Medication Error in Anesthesia Continues to Occur : 

Why Medication Error in Anesthesia Continues to Occur It is not difficult to inject 1 drug safely, but an anesthesiologist administers half a million drugs during a professional lifetime. Doing this with 100% accuracy is very difficult. Many of our patients have diminished physiologic reserve to tolerate drug error. As they are sedated or anesthetized they cannot correct or detect drug errors themselves. They depend on us to do this, and this is a responsibility we should not take lightly.

GLOBAL EFFORTS -APSF : 

GLOBAL EFFORTS -APSF At the 1984 meeting of the American Society of Anesthesiologists, Dr. Ellison C.Pierce, the Society's President, inaugurated the “Anesthesia Patient Safety Foundation” (APSF). Its goals were clearly stated: to assure that no patient shall be harmed by the effects of anesthesia. to foster investigations that will provide a better understanding of preventable anesthetic injuries; encourage programs that will reduce the number of anesthetic injuries; and promote national and international communication of information and ideas about the causes and prevention of anesthetic morbidity and mortality."

Patient Safety in Anesthesia-A success story : 

Patient Safety in Anesthesia-A success story December 7, 1941  Pearl Harbor.... Lots of casualties. finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Anesthesia-related death rate reported at 1 in 450 . September 1979 – September 1981 The operating surgeon calmly notes blood’s dark.!! So Anaesthetist checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; Did have manual blood pressure cuffs, ECG machines,  and the beginnings of advanced Hemodynamic monitoring. No monitors other than his five senses.  Anesthesia death rate said to be about 1 in 10,000.

Scenario in -2007. : 

Scenario in -2007. Cyanosis is virtually never seen by trainees and death by disconnect is now  unheard of. Gas analyzers, pulse oximetry, end-tidal CO2, NIBP monitors, Anaesth.Work stations and many more are part of the modern anesthesia tool box. Anesthesia death rate in healthy patients thought to be about 1 in 200,000 -300,000 Remarkable progress indeed !

ANAESTHESIA IS MUCH SAFER NOW ! : 

ANAESTHESIA IS MUCH SAFER NOW ! Medical errors are a leading cause of death in the U.S., killing between 44,000 and 98,000 Americans each year In last 20 yrs the rates of insurance premiums charged from Anaesthesiologists in US has fallen considerably due to safety of anaesthesia practice

ANAESTHESIA IS MUCH SAFER NOW : 

ANAESTHESIA IS MUCH SAFER NOW Over the years, anesthesiology has demonstrated leadership in patient safety and anesthesia-related mortality has decreased considerably. However, still much work to be done and complacency is unwarranted

Slide 90: 

In the magazine of Delta Airlines (June 1995), Delta's CEO declared in an article: "Safety is Delta's top priority every hour of every day“ We should say no less. “Our patients deserve to hear how we work to make anesthesia safe for them. Even safer than it is today. We have a long way to go to make anesthesia as safe as possible.” J. S. Gravenstein, M.D

Our Vision : 

Our Vision “That no patient shall be harmed by anesthesia”

LET US CHANGE OUR SELVES : 

LET US CHANGE OUR SELVES ADOPT SAFE PRACTICES DON’T COMPROMISE WITH THE SAFETY FOLLOW MINIMUM MONITORING STD 2008 International Standards for a Safe Practice of Anaesthesia adopted by the World Federation of Societies of Anaesthesiologists 13 June 1992) ALWAYS READ AN AMPOULE/VIAL FOR CONTENTS ADOPT LABELLING OF SYRINGES USE DIFFERENT SIZE SYRINGES FOR DIFFERENT GROUPS RFISA MAY INTRODUCE SYSTEM OF “ANAONYMOUS ERROR REPORTING & REVIEW” TO IMPROVE THE SAFE PRACTICES IN ANAESTHESIA OVER INDIAN RAILWAYS

THANKS FOR YOUR PATIENCE : 

THANKS FOR YOUR PATIENCE