imageWashington—Although nearly 15% of hospital-based anesthesia occurs outside the operating room, clinicians have little data on rates of morbidity and mortality in these locations.
But the evidence that does exist points to a cause for concern. A new study by California researchers shows that near misses in non–operating room anesthesia (NORA) may be on the rise, a significant worry given that adverse events in these locations are associated with a higher severity of injury and are more likely to result in death than those occurring in operating rooms (Curr Opin Anaesthesiol 2006; 19:436-442).
“My clinical experience suggested that provision of anesthesia outside the operating room was becoming increasingly common, and that patients undergoing procedures in remote locations could be quite ill, with multiple comorbidities,” said Angela Lipshutz, MD, MPH, a critical care fellow at the University of California, San Francisco School of Medicine. “I was concerned that provision of anesthesia in remote locations may be associated with increased risk, and that patterns of failure may be different from those associated with the provision of anesthesia in the operating room.”
With that in mind, Dr. Lipshutz and her colleagues analyzed reports submitted to the institution’s near-miss reporting system between Jan. 1, 2009, and Dec. 31, 2011. Each report contains a description of the near miss, its location and time of day (day vs. night/weekend) and cause based on the Joint Commission’s patient safety event taxonomy. The investigators compared causative mechanisms between near-miss reports occurring in the operating room and remote locations.
As Dr. Lipshutz reported at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 055), the system contained 2,485 near-miss reports, 220 of which (8.9%) involved patients treated in remote locations. The proportion of near-miss reports from these locations increased each year throughout the three-year period, from 5.1% to 12.2% to 13.8% (P<0.05).
Nearly half of the near misses outside the operating room resulted from either equipment malfunction or the failure of a clinician to use appropriate technique (Table). A poor culture of safety also played a significant role, accounting for nearly 15% of near misses in NORA patients, according to the researchers. Perhaps not surprisingly, these near misses were nearly twice as likely to be associated with this poor safety culture as those occurring in operating rooms (odds ratio 1.92; 95% confidence interval, 1.28-2.88).
Table. Primary Causes of
Near Misses Originating FromNon–Operating Room Anesthesia
Failure to execute a skill at expected level4620.91
Equipment malfunction4219.09
Poor culture of safety3214.55
Faulty design2210.00
Rule-based: failure to perform routine task219.55
Equipment availability188.18
Poor communication104.55
Failures related to patient factors beyond control of institution62.73
Insufficient resources52.27
Knowledge-based: Incomplete52.27
Time pressure31.36
Inadequate documentation31.36
Lack of training20.91
Knowledge-based: Incorrect20.91
Faulty construction10.45
Lack of supervision10.45
Non–operating room near misses did not differ from those in the operating room with respect to the time the event occurred (79% vs. 83% during the day, respectively; P=0.19), attribution to systems rather than human error (63% for both locations; P=0.99) or association with technical issues (39% vs. 43%; P=0.28).
Dr. Lipshutz acknowledged that the study is limited by its retrospective design and the limited amount of data collected by the institution’s near-miss reporting system, which is designed to encourage providers by minimizing the time required to report an event. As such, she called for more research making definitive recommendations. “I think, based on our data, anesthesiologists should be aware of the common causative mechanisms associated with near misses in remote locations, and should maintain constant vigilance,” she said. “Vigilance at the level of the anesthesiologist includes things such as performing machine and equipment checks prior to each case.
“A small number of causative mechanisms explained the bulk of near misses reported and can guide interventions to make NORA safer,” Dr. Lipshutz continued. “Additionally, promotion of a culture of safety in remote locations is needed.”
Although Ashish Sinha, MD, PhD, agreed on the importance of physician vigilance, he also questioned the role that institutions might play in non–operating room anesthesia near misses. “Thirty percent of the near misses in this study are due to equipment issues,” said the professor and vice chair of anesthesiology and perioperative medicine at Drexel University College of Medicine, in Philadelphia. “I presume this is easily fixed, with enough resources. Moreover, less than 3% of failures were related to factors beyond the control of the institution. What is the institution doing to change the 97% it has influence over?”
“While it is indeed true that only 3% of failures are related to patient factors beyond the control of the institution,” Dr. Lipshutz said, “it does not necessarily follow that 97% of failures could be fixed by the institution.”