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Re-lie-ability as an issue
RISK M A N A G E M E N T : ISSUES A N D CASES
Re-Lie-Ability as an Issue Wayne Kaufman and Stephen N. Steen NESTHESIOLOGISTS require accurate information before the administration of anesthetics to patients. During the preoperative evaluation, numerous individuals provide information so that a determination may be made as to whether the risk is acceptable for a patient to undergo surgery/anesthesia. The intraoperative practice of modern anesthesia involves a large number of monitoring devices producing moment-to-moment data about the patient at any given time. Such data are used in the decision-making process required during an operative procedure. Inaccurate data may lead the anesthesiologist to provide a course of action that could compromise the patient's care. The following three case reports are presented to enable discussion of whether an anesthesiologist can rely on the information provided by other health care providers.
A
CASE NO. 1 A patient was undergoing an elective morning cystoscopy in an operating room under local anesthesia administered by the surgeon. The patient was sedated, but despite the surgeon's best attempts to make the patient comfortable, the patient struggled. The surgeon finally realized that he could not both perform the prdcedure and sedate the patient, so he called for an anesthesiologist. The anesthesiologist entered the operating room and was asked by the surgeon to sedate the patient. The patient was too heavily sedated to respond to questions. Rather than looking through the chart, the anesthesiologist asked the surgeon about the patient's medical history as well as the patient's NPO status. The surgeon stated that the patient had no major medical problems and that the patient had NPO for at least 8 hours. The anesthesiologist decided on the basis of this information that it would be safe to proceed, and medicated the patient so that he could administer anesthesia with a mask. Shortly thereafter, the patient vomited, aspirated, and developed pneumonitis. The patient was brought to intensive care unit after surgery and had a long and difficult recovery. On review of the chart, it
was noted that the patient had eaten breakfast as per the written order of the attending surgeon. CASE NO. 2 An anesthesiologist was evaluating a patient for a major elective thyroidectomy. He was unable to complete the evaluation because he could not locate the chest x-ray film or the findings thereof. He contacted the surgeon, who told the anesthesiologist that he had seen the chest x-ray film and that it was "fine." Shortly following the induction of anesthesia, the patient desaturated to 88% to 92%. Surgery proceeded while the anesthesiologist attempted to determine the course of the decrease (checking the endotrachial tube, suctioning, requesting arterial blood gas values, etc). The anesthesiologist interrupted the operative procedure so that a chest x-ray film could be obtained. The chest film indicated a major infectious process in all areas of the lungs. The surgeon quickly finished the procedure and the patient was brought to the intensive care unit. Shortly thereafter, the original chest x-ray film was found and appeared almost identical to the intraoperative film. CASE NO. 3 A 45-year-old, 235-1b, 5-foot 6-inch man was scheduled for an elective right knee arthroscopy. Preoperative work-up indicated an ST depression greater than 1 minute. According to the surgeon, the patient's condition did not warrant further medical work-up. Following an uneventful surgery/anesthesia, the patient was discharged to his room from the post-operative recovery room awake and in stable condition. Forty-five minutes later, he was found dead in his bed. Postmortem findings indicated a myocardial infarction.
From the Department of Anesthesiology, University of Southern California School of Medicine, Los Angeles, CA. Address reprint requests to Wayne Kaufman, MD, Department of Anesthesiology, University of Southern California School of Medicine, 1200 N State St, Room 14-901, Los Angeles, CA 90033. Copyright 9 1998 by W.B. Saunders Company 0277-0326/98/1701-0011 $8.00/0
Seminars in Anesthesia, Perioperative Medicine and Pain, Vol 17, No 1 (March), 1998: p 83-85
83
84
KAUFMAN AND STEEN DISCUSSION
These three cases demonstrate what can happen when the anesthesiologist uses inaccurate information. Clearly, if the anesthesiologists had possessed the correct information and still proceeded as they did, they would have been practicing "below the standard of care." Yet the question remains, while the anesthesiologists were misled by the surgeons, were they still negligent because they failed to make'reasonable efforts to determine the veracity of the information? Before proceeding with an analysis, the types of cases under consideration should be defined. There are three important points relative to these three cases: (1) the surgeries were elective in nature, so that there was time to seek alternative sources of information; (2) the information that was at issue was, of course, critical to the decision-making process of the anesthesiologist; and (3) the information in question was or should have been known by other physicians or health care providers. The anesthesiologist relies on information from many different sources to help make decisions during surgery. Some of these come from sources before the operation (ie, laboratory results, x-ray films, patient history, and other medical consultations). This information helps the anesthesiologist to formulate a perioperative plan. During the operation, the anesthesiologist relies on data provided from monitors applied to the patients, from the surgeon/'and from the patient's responses. Most of the time, the information is used to determine how the patient is faring, whether the patient is comfortable (if conscious) and surgically relaxed, and to chart that the operation is following the perioperafive plan. Sometimes these findings indicate to the anesthesiologist that something is critically wrong, allowing the anesthesiologist to correct the situation. Information is only as good as its source. GIGO (garbage in, garbage out) is a common acronym to describe what happens when invalid data are used in the decision-making process. For the anesthesiologist, this " g a r b a g e " can lead to critical errors in the patient's care. It thus becomes incumbent to ensure that decisions are based on true data. For example, suppose that the anesthesiologist is in the operating room with an otherwise stable
patient when the blood pressm'e monitor alarm suddenly indicates a reading of 200/120 m m Hg. However, a review of the other monitors reveals no change in either the heart rate or oxygen saturation. Should the anesthesiologist treat the patient for hypertension immediately or should he recheck the blood pressure? It is fairly safe to say that most physicians in this situation would recheck the blood pressure. This is because the relative ease of rechecking the blood pressure is low (knowing that values derived from the blood pressure are hardly infallible), and that the lack of other confirmatory data and the harm from treating nonexistant hypertensions is potentially significant. Clearly, the anesthesiologist is faced with a possible overload of information. Most of the information that the anesthesiologist receives merely confirms what the anesthesiologist believes is occurring. The O2-saturation monitor usually reads between 95% and 100%. The anesthesiologist will probably not feel the need to recheck the saturation unless some other event leads the anesthesiologist to question the number. If the anesthesiologist did not do this, all his or her time would be spent rechecking the data rather than caring for the patient. Thus, the anesthesiologist must carefully choose when to take the time to check the data from the monitors. This usually will occur when the data, if true, would cause the anesthesiologist to change the care the patient is currently receiving. The anesthesiologist must also weigh the need for checking the data from the monitors, taking into accountnot only the monetary cost, but also the cost in time expended as well as the risks associated with the confirming procedures. Thus, were the pulse oximeter value to suddenly decrease, the anesthesiologist could recheck the placement of the oxygen sensor or check the values of an arterial blood gas analysis, which may harm the patient from the insertion of a catheter. Checking the placement of the oxygen sensor is less expensive and also less risky than drawing an arterial blood sample for analysis. In addition to considering the " w h e n " and " h o w " of rechecking information, the anesthesiologist must also consider the source and its accuracy. This can take several forms, as there are many different aspects of the source that can affect its accuracy.
RE-LIE-ABILITY AS AN ISSUE For example, two similar blood pressure machines may have been maintained differently, thus leading to greater inaccuracy of one of the machines. Furthermore, there are many different ways to acquire the same information that differ in their accuracy rates. An arterial line may be more accurate than a blood pressure monitor, and thus less rechecking of its results may be required. These are only some of the factors that the anesthesiologist must consider when trying to decide whether to trust the data reported by the monitors in the operating room. A machine is, of course, just a machine. The machines (monitors) make no decisions, simply following their programmed instructions and re~ porting the results to whoever happens to read them. If an anesthesiologist blindly uses the information to make decisions affecting patient care, he or she would be practicing foolishly and potentially negligently. Society expects the welltrained anesthesiologist to use his or her expertise to determine the accuracy and response to the data the monitors present. Fortunately, since the practice of anesthesia requires the use of many monitors and these monitors analyze conditions that are interrelated (ie, the pulse oximeter measures 02 saturation as well as pulse rate, which should match the heart rate of the electrocardiogram or the pulse measurement of the blood pressure cuff), there are many cross-checks for the anesthesiologist to rely on to determine the reliability of the machine data. Unfortunately, while machines tend to be insensitive to the anesthesiologist's decision not to trust the data they report, humans tend to act quite differently when we question their accuracy. This is unfortunate because the information we obtain from our colleagues is at least as important, if not more so, as that reported by our monitors. The question remains, though, " W h a t is t h e anesthesiologist's duty with respect to checking the accuracy of information provided by other physicians?" In the cases presented, the anesthesiologist acted on the basis of information provided by other physicians. This is the case for most surgical procedures. The anesthesiologist often will read medical reports by other physicians discussing the various medical problems of the pa-
85 tient. Some of the data in these reports will be confirmed by the anesthesiologist during the examination of the patient. It is most likely that the anesthesiologist will trust the medical reports unless something is found during the examination that directly contradicts a finding in the medical reports. If the anesthesiologist discovers some fact that does contradict another physician's findings, it is incumbent on him or her to investigate further. The information in the three cases presented did not require the expertise of an anesthesiologist, and arguably not even a medical degree! The x-ray film did not require a physician to determine it was abnormal; a radiology technician could have seen the abnormal findings. In the patient who was not NPO before surgery, a mere check of the patient's chart would have confirmed this fact. Yet, the anesthesiologist relied on incorrect statements by the surgeons, without otherwise determining the veracity of the surgeons' claims, leading to the patient's subsequent injuries. Accordingly and unfortunately, for these three cases, we consider that the anesthesiologist was, to a degree, culpable, because there was sufficient time to validate the statements and data, and these cases were not emergencies. One of the factors that needs to be taken into account is the status (elective, emergent) of the case. When the procedure is a true emergency, reliance on " w o r d of mouth" becomes of more import, certainly with regard to fluid (blood) loss, trauma, etc. The induction of anesthesia is somewhat simplified in that we tend to follow the principles of ABC (sequentially; ie, airway, breathing, circulation) by intubating (using a rapid sequence induction technique, generally with cricoid pressure, on the assumption that all such patients have a full stomach) and then instituting appropriate resuscitative measures for optimizing the cardiovascular system status. Since time is of the essence, there is a greater necessity to rely on the information provided by other physicians, which is in part because of the limited options available to the anesthesiologist in an emergency and also because the time required to determine the accuracy of the information could detrimentally delay patient care.
Re-Lie-Ability as an Issue Wayne Kaufman and Stephen N. Steen NESTHESIOLOGISTS require accurate information before the administration of anesthetics to patients. During the preoperative evaluation, numerous individuals provide information so that a determination may be made as to whether the risk is acceptable for a patient to undergo surgery/anesthesia. The intraoperative practice of modern anesthesia involves a large number of monitoring devices producing moment-to-moment data about the patient at any given time. Such data are used in the decision-making process required during an operative procedure. Inaccurate data may lead the anesthesiologist to provide a course of action that could compromise the patient's care. The following three case reports are presented to enable discussion of whether an anesthesiologist can rely on the information provided by other health care providers.
A
CASE NO. 1 A patient was undergoing an elective morning cystoscopy in an operating room under local anesthesia administered by the surgeon. The patient was sedated, but despite the surgeon's best attempts to make the patient comfortable, the patient struggled. The surgeon finally realized that he could not both perform the prdcedure and sedate the patient, so he called for an anesthesiologist. The anesthesiologist entered the operating room and was asked by the surgeon to sedate the patient. The patient was too heavily sedated to respond to questions. Rather than looking through the chart, the anesthesiologist asked the surgeon about the patient's medical history as well as the patient's NPO status. The surgeon stated that the patient had no major medical problems and that the patient had NPO for at least 8 hours. The anesthesiologist decided on the basis of this information that it would be safe to proceed, and medicated the patient so that he could administer anesthesia with a mask. Shortly thereafter, the patient vomited, aspirated, and developed pneumonitis. The patient was brought to intensive care unit after surgery and had a long and difficult recovery. On review of the chart, it
was noted that the patient had eaten breakfast as per the written order of the attending surgeon. CASE NO. 2 An anesthesiologist was evaluating a patient for a major elective thyroidectomy. He was unable to complete the evaluation because he could not locate the chest x-ray film or the findings thereof. He contacted the surgeon, who told the anesthesiologist that he had seen the chest x-ray film and that it was "fine." Shortly following the induction of anesthesia, the patient desaturated to 88% to 92%. Surgery proceeded while the anesthesiologist attempted to determine the course of the decrease (checking the endotrachial tube, suctioning, requesting arterial blood gas values, etc). The anesthesiologist interrupted the operative procedure so that a chest x-ray film could be obtained. The chest film indicated a major infectious process in all areas of the lungs. The surgeon quickly finished the procedure and the patient was brought to the intensive care unit. Shortly thereafter, the original chest x-ray film was found and appeared almost identical to the intraoperative film. CASE NO. 3 A 45-year-old, 235-1b, 5-foot 6-inch man was scheduled for an elective right knee arthroscopy. Preoperative work-up indicated an ST depression greater than 1 minute. According to the surgeon, the patient's condition did not warrant further medical work-up. Following an uneventful surgery/anesthesia, the patient was discharged to his room from the post-operative recovery room awake and in stable condition. Forty-five minutes later, he was found dead in his bed. Postmortem findings indicated a myocardial infarction.
From the Department of Anesthesiology, University of Southern California School of Medicine, Los Angeles, CA. Address reprint requests to Wayne Kaufman, MD, Department of Anesthesiology, University of Southern California School of Medicine, 1200 N State St, Room 14-901, Los Angeles, CA 90033. Copyright 9 1998 by W.B. Saunders Company 0277-0326/98/1701-0011 $8.00/0
Seminars in Anesthesia, Perioperative Medicine and Pain, Vol 17, No 1 (March), 1998: p 83-85
83
84
KAUFMAN AND STEEN DISCUSSION
These three cases demonstrate what can happen when the anesthesiologist uses inaccurate information. Clearly, if the anesthesiologists had possessed the correct information and still proceeded as they did, they would have been practicing "below the standard of care." Yet the question remains, while the anesthesiologists were misled by the surgeons, were they still negligent because they failed to make'reasonable efforts to determine the veracity of the information? Before proceeding with an analysis, the types of cases under consideration should be defined. There are three important points relative to these three cases: (1) the surgeries were elective in nature, so that there was time to seek alternative sources of information; (2) the information that was at issue was, of course, critical to the decision-making process of the anesthesiologist; and (3) the information in question was or should have been known by other physicians or health care providers. The anesthesiologist relies on information from many different sources to help make decisions during surgery. Some of these come from sources before the operation (ie, laboratory results, x-ray films, patient history, and other medical consultations). This information helps the anesthesiologist to formulate a perioperative plan. During the operation, the anesthesiologist relies on data provided from monitors applied to the patients, from the surgeon/'and from the patient's responses. Most of the time, the information is used to determine how the patient is faring, whether the patient is comfortable (if conscious) and surgically relaxed, and to chart that the operation is following the perioperafive plan. Sometimes these findings indicate to the anesthesiologist that something is critically wrong, allowing the anesthesiologist to correct the situation. Information is only as good as its source. GIGO (garbage in, garbage out) is a common acronym to describe what happens when invalid data are used in the decision-making process. For the anesthesiologist, this " g a r b a g e " can lead to critical errors in the patient's care. It thus becomes incumbent to ensure that decisions are based on true data. For example, suppose that the anesthesiologist is in the operating room with an otherwise stable
patient when the blood pressm'e monitor alarm suddenly indicates a reading of 200/120 m m Hg. However, a review of the other monitors reveals no change in either the heart rate or oxygen saturation. Should the anesthesiologist treat the patient for hypertension immediately or should he recheck the blood pressure? It is fairly safe to say that most physicians in this situation would recheck the blood pressure. This is because the relative ease of rechecking the blood pressure is low (knowing that values derived from the blood pressure are hardly infallible), and that the lack of other confirmatory data and the harm from treating nonexistant hypertensions is potentially significant. Clearly, the anesthesiologist is faced with a possible overload of information. Most of the information that the anesthesiologist receives merely confirms what the anesthesiologist believes is occurring. The O2-saturation monitor usually reads between 95% and 100%. The anesthesiologist will probably not feel the need to recheck the saturation unless some other event leads the anesthesiologist to question the number. If the anesthesiologist did not do this, all his or her time would be spent rechecking the data rather than caring for the patient. Thus, the anesthesiologist must carefully choose when to take the time to check the data from the monitors. This usually will occur when the data, if true, would cause the anesthesiologist to change the care the patient is currently receiving. The anesthesiologist must also weigh the need for checking the data from the monitors, taking into accountnot only the monetary cost, but also the cost in time expended as well as the risks associated with the confirming procedures. Thus, were the pulse oximeter value to suddenly decrease, the anesthesiologist could recheck the placement of the oxygen sensor or check the values of an arterial blood gas analysis, which may harm the patient from the insertion of a catheter. Checking the placement of the oxygen sensor is less expensive and also less risky than drawing an arterial blood sample for analysis. In addition to considering the " w h e n " and " h o w " of rechecking information, the anesthesiologist must also consider the source and its accuracy. This can take several forms, as there are many different aspects of the source that can affect its accuracy.
RE-LIE-ABILITY AS AN ISSUE For example, two similar blood pressure machines may have been maintained differently, thus leading to greater inaccuracy of one of the machines. Furthermore, there are many different ways to acquire the same information that differ in their accuracy rates. An arterial line may be more accurate than a blood pressure monitor, and thus less rechecking of its results may be required. These are only some of the factors that the anesthesiologist must consider when trying to decide whether to trust the data reported by the monitors in the operating room. A machine is, of course, just a machine. The machines (monitors) make no decisions, simply following their programmed instructions and re~ porting the results to whoever happens to read them. If an anesthesiologist blindly uses the information to make decisions affecting patient care, he or she would be practicing foolishly and potentially negligently. Society expects the welltrained anesthesiologist to use his or her expertise to determine the accuracy and response to the data the monitors present. Fortunately, since the practice of anesthesia requires the use of many monitors and these monitors analyze conditions that are interrelated (ie, the pulse oximeter measures 02 saturation as well as pulse rate, which should match the heart rate of the electrocardiogram or the pulse measurement of the blood pressure cuff), there are many cross-checks for the anesthesiologist to rely on to determine the reliability of the machine data. Unfortunately, while machines tend to be insensitive to the anesthesiologist's decision not to trust the data they report, humans tend to act quite differently when we question their accuracy. This is unfortunate because the information we obtain from our colleagues is at least as important, if not more so, as that reported by our monitors. The question remains, though, " W h a t is t h e anesthesiologist's duty with respect to checking the accuracy of information provided by other physicians?" In the cases presented, the anesthesiologist acted on the basis of information provided by other physicians. This is the case for most surgical procedures. The anesthesiologist often will read medical reports by other physicians discussing the various medical problems of the pa-
85 tient. Some of the data in these reports will be confirmed by the anesthesiologist during the examination of the patient. It is most likely that the anesthesiologist will trust the medical reports unless something is found during the examination that directly contradicts a finding in the medical reports. If the anesthesiologist discovers some fact that does contradict another physician's findings, it is incumbent on him or her to investigate further. The information in the three cases presented did not require the expertise of an anesthesiologist, and arguably not even a medical degree! The x-ray film did not require a physician to determine it was abnormal; a radiology technician could have seen the abnormal findings. In the patient who was not NPO before surgery, a mere check of the patient's chart would have confirmed this fact. Yet, the anesthesiologist relied on incorrect statements by the surgeons, without otherwise determining the veracity of the surgeons' claims, leading to the patient's subsequent injuries. Accordingly and unfortunately, for these three cases, we consider that the anesthesiologist was, to a degree, culpable, because there was sufficient time to validate the statements and data, and these cases were not emergencies. One of the factors that needs to be taken into account is the status (elective, emergent) of the case. When the procedure is a true emergency, reliance on " w o r d of mouth" becomes of more import, certainly with regard to fluid (blood) loss, trauma, etc. The induction of anesthesia is somewhat simplified in that we tend to follow the principles of ABC (sequentially; ie, airway, breathing, circulation) by intubating (using a rapid sequence induction technique, generally with cricoid pressure, on the assumption that all such patients have a full stomach) and then instituting appropriate resuscitative measures for optimizing the cardiovascular system status. Since time is of the essence, there is a greater necessity to rely on the information provided by other physicians, which is in part because of the limited options available to the anesthesiologist in an emergency and also because the time required to determine the accuracy of the information could detrimentally delay patient care.