Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
John@DanielJohnDoyle.com 1. INCOMPLETE ASSESSMENT Not obtaining the necessary preoperative information to provide safe anaesthesia. However, in some emergency situations (e.g. ruptured aortic aneurysm, massive trauma) there may be insufficient time to perform a complete patient assessment (e.g. medical history, allergies, previous anaesthetics, etc.). Other potential impediments include language barriers and patient’s cognitive impairment (e.g. Altzheimer’s disease). Important information in the patient’s old medical records may be unavailable because files may be destroyed after a time period (e.g. 10 years), or stored off-site or unavailable only on microfilm during “normal business hours”. Often old records are unavailable for no obvious reason (“lost”) or available only on 48 hours notice. 2. POOR PREPARATION Not checking the anaesthesia machine and equipment before starting the case. Proper preparation for providing an anaesthetic includes: ♦ Anaesthetic machine and monitoring equipment check ♦ Check for suction apparatus ♦ Preparation of airway equipment (e.g. laryngoscope, ETT) ♦ Preparation of syringe of anaesthetic and resuscitation drugs ♦ Preparation of IV equipment ♦ Obtaining specialised items (e.g. heating equipment, cardiac output computer, etc.) ♦ This process can be facilitated by use of a checklist. The specific choices of drugs to be drawn up and equipment to be made available will of course, depend on clinical circumstances 3. NOT KNOWING WHAT THE SURGEON IS DOING Examples include: ♦ Not having an accurate estimate of blood loss ♦ Using halothane when the surgeon is infiltrating the field with epinephrine solution ♦ Not knowing how much local anaesthetic the surgeon has used ♦ Not noticing that the surgeon is pulling the eyeball (causing bradycardia). 4. SLOTH Examples include: ♦ Not keeping up with charting over time ♦ Incomplete charting (no temperature, no airway pressure) ♦ Not ever measuring patient’s BP manually to validate abnormal BP measurements. 5. PRIDE AND OVERCONFIDENCE Overconfidence may lead a clinician to inadequately prepare for a case (e.g. not arranging for a “difficult intubation cart” in a patient who was previously difficult to intubate). The overly proud clinician may fail for call for needed assistance when needed (e.g. difficult intubation, massive bleeding, anaphylaxis). 6. DISORGANIZATION Examples include: ♦ Not labelling IV lines in complex cases ♦ Not labelling syringes ♦ Untidy, disorganized working surface. 7. APATHY Examples include: ♦ Not identifying and dealing with problems such as faulty equipment, under-stocked drug charts, etc. ♦ Not attempting to keep current by reading and discussion