1. We Can’t Fix What We Don’t Know Awareness and Anaphylaxis incidents amongst the first 4,000 reports submitted to webAIRS Dr Martin Culwick Medical Director
Dr Heather Reynolds Data Analyst The Australian and New Zealand Tripartite Anaesthetic Data Committee (ANZTADC); Department of Anaesthesia and Perioperative Medicine, Royal Brisbane & Women’s Hospital; The University of Queensland, Queensland, Australia

2. No conflicts of interest
Aims
Analysis of anaesthetic incidents using webAIRS
What we do not know:
What we think we know
Awareness data
Anaphylaxis data
Fixing what we have found:
Hierarchy of error reduction strategies
The two steps of error reduction
The Bowtie diagram to summarise the findings
No conflicts of interest

3. Update

4. Incidents – Main Categories
750 per year – Tip of the iceberg

6. What do we already know? Internet searches Text books Journal articles
Evidence Based Medicine
Registries and big data

7. Text Book Example: Face Mask Ventilation
Miller – Testing FMV before giving a muscle relaxant (1990)
Kheterpal et al
NAP 4
ANZCA Guideline

10. Awareness Potential Hazard No Harm or Near Miss
Anaesthesia and Intensive Care Vol 45, 2017, Issue 4, p441-7
Awareness
Potential Hazard
No Harm or Near Miss

11. Awareness
Awareness is postoperative recall of events during intended general anaesthesia, arising when anaesthetic delivery does not meet the patient’s context-specific anaesthetic requirement for amnesia for intraoperative events
Awareness is unusual, occurring in only % of patients having general anaesthesia for surgery
Awareness has the potential for a severe adverse impact on the patient’s experience
Incident monitoring provides a view of the types of critical incidents associated with awareness, facilitating improvement of risk assessment

12. Reports of anaesthetic incidents were voluntarily submitted by clinicians to webAIRS from registered hospitals: a) A main category for the incident was selected from a pre-existing list b) A related subcategory was then selected from drop-down boxes c) The report included a narrative description of the incident, demographic patient information, details of the surgical procedure, type of anaesthesia and drugs administered
Awareness

13. Awareness
The database was searched using the following strategies to find incidents reporting “awareness” as the primary incident, or as a secondary consequence Search terms were “neurological” as main category and “awareness/dreaming/nightmares” as subcategory The narrative description was searched separately for the term “awareness” Reports were reviewed as relevant from the context of the narrative, including incidents related to medication errors

14. Awareness
Incidents were classified using an adaption of Bergman’s classification (2002):
a) Awareness
b) No awareness but increased risk of awareness
c) No awareness and no increased risk of awareness

15. Results 61 incidents identified from search
16 incidents classified as “awareness”
4 (25%) → pEEG monitoring
15 (94%) → muscle relaxants
4 (25%) → propofol
12 (75%) → volatile anaesthesia maintenance
8 (50%) → signs of intraoperative wakefulness
6 (69%) → low anaesthetic delivery

16. Analysis of “awareness” incidents (n=16)

17. Analysis of 61 incidents

18. Issues involved
Common clinical errors put patients at risk for “awareness” →
Failure to check equipment
Failure to turn on vaporisers
Failure to maintain anaesthesia during difficult intubation and other crisis management situations
Failure to monitor and adequately reverse neuromuscular blockade
Mistakenly giving muscle relaxants to awake patients

19. Issues involved (continued)
Electronic anaesthesia workstation errors with increased risk for patient “awareness” →
Age-adjusted minimum alveolar concentration for previous patient was inadvertently used to guide anaesthetic delivery for the subsequent patient
Volatile administration stopped because of failure to confirm a new target concentration on the workstation
Failure to note that the target-controlled infusion device reset to zero when the alarm settings were changed

20. Interventions Rules, policies, education, news and publications
Equipment
Alarms - pEEG, Volatile %, MAC, Syringe driver etc
And Cross Check
Work process change -
Stop – Preparing and labeling drugs
Stop - Before giving a drug
Stop - After induction
Stop - After topping up a vapouriser or changing a TIVA syringe
Stop - After or during a critical event
Stop - Periodically during a case and then scanning the environment

21. Equipment Work process change Stop and Cross Check New policy
Available and used
Alarms –
pEEG, Volatile %, MAC,
Syringe driver etc (ensure activated)
Work process change
Stop and Cross Check
New policy
News & Publications
Education and training

22. Awareness Bowtie Diagram

23. The webAIRS incident reporting system includes individual de-identified incidents with reports related to anaphylaxis during anaesthesia
Anaphylaxis is an acute, severe, life-threatening allergic reaction in pre-sensitized individuals, leading to a systemic response caused by the release of immune and inflammatory mediators from basophils and mast cells
Anaphylaxis

24. At least 2 organ systems are involved, such as the skin, the upper and lower airways, the cardiovascular, neurologic, and GI systems, in this order of priority or in combination.
Allergy to medications is a frequent cause. Similar symptoms caused by nonimmunologic mechanisms are termed anaphylactoid reactions.
Anaphylaxis

25. Anaphylaxis Key diagnostic factors hypotension bronchospasm urticaria
angioedema
flushing
Treatment
ABC approach
early administration of adrenaline

26. Anaphylaxis – 205 cases in first 4000

27. What can we do to improve outcomes from anaphylaxis?
Prevention – difficult except by checklist for prior episode
Management
System factors
Anaphylaxis Kit
Human factors
Checklists and Diagnostic Card
Training, simulation and emergency response wokshops
Education

28. WebAIRS Data - diagnosis CVS 720 18% Resp 1172 29%
Anaphylaxis 205 Reports
First 4000 Reports
System
Clinical Signs
Count
Percent
First Sign
CVS
Conscious Level 15
7.3% 2
1.0%
720
18%
Arrythmia 12
5.9%
Bradycardia 13
6.3% 1
0.5%
Tachycardia 81
39.5% 25
12.2%
Cardiac Arrest 41
20.0% 7
3.4%
Hypotension
179
87.3% 77
37.6%
Resp
Airway Oedema
1172
29%
Bronchospasm 54
26.3% 10
4.9%
Cough 9
4.4%
CO2 32
15.6% 8
3.9%
Desaturation 59
28.8% 6
2.9%
High Ventilation Pressure 63
30.7% 26
12.7%
Other 30
14.6%
Skin
Angioedema (Skin) 22
10.7%
Rash
124
60.5% 19
9.3%
Disclaimer: Results displayed are preliminary and require confirmation
Downloaded on 9th May 2017 from f

30. Additional
Disclaimer: Results displayed are preliminary and require confirmation

31. Disclaimer: Results displayed are preliminary and require confirmation
Cardiovascular System
Adrenaline Infusion
Noradrenaline Infusion
Metaraminol infusion
Phenylephrine Infusion
Glucagon
Vasopressin
ECMO or CPB
DCCV
Yes
121 28 7 17 1 10 5 8
Percent
59.0%
13.7%
3.4%
8.3%
0.5%
4.9%
2.4%
3.9%
Respiratory
Salbutamol Inhalational
Salbutamol IV
Magnesium
Aminophylline
Inhalational Anaes. Agents
Ketamine
Yes
Percent 18 12 8 3 7
8.8%
5.9%
3.9%
1.5%
3.4%
Downloaded on 9th May 2017 from f
Disclaimer: Results displayed are preliminary and require confirmation

32. Anaphylaxis – Bowtie Diagram

33. Two Steps To Making Effective Changes
More complex, more expensive, and take longer to implement but potentially much more effective
Work process change
Checklists
Recommendations
News & Publications
Education and training
Step 1
Easy
Low Cost
Important
N.B.
The information is not usually available at point of care in a format where it is practical to use
We already have these interventions in place

34. Summary Analysis of anaesthetic incidents using webAIRS
What we do not know
What we think we know
Awareness data
Anaphylaxis data
Fixing what we have found
Hierarchy of error reduction strategies
Two steps to effective changes
The Bowtie Diagram to summarise the findings

35. Conclusion Build a safety culture
Promote anaesthetic incident recording
Implement safety solutions to prevent harm
Always look for two steps to reduce errors
1. Quick and easier to implement
2. More complex and expensive but more effective

36. 1. Mahajan RP. Critical incident reporting and learning
1. Mahajan RP. Critical incident reporting and learning. Br J Anaesth 2010;105: Runciman WB, Sellen A, Webb RK, Williamson JA, Currie M, Morgan C, Russell WJ. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993;21: Gibbs NM, Culwick M, Merry AF. A cross-sectional overview of the first 4,000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Anaesth Intensive Care 2017;45:28-35.
References

37. 4. Gibbs NM, Culwick MD, Merry AF
4. Gibbs NM, Culwick MD, Merry AF. Patient and procedural factors associated with an increased risk of harm or death in the first 4,000 incidents reported to webAIRS. Anaesth Intensive Care 2017;45: Ghoneim M. Awareness during anesthesia. Anesthesiology 2000;92: Myles P, Williams D, Hendrata M, Anderson H, Weeks A. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of patients. Br J Anaesth 2000;84:6-10.
References

38. 7. Sandin R, Enlund G, Samuelsson P, Lennmarken C
7. Sandin R, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: a prospective case study. Lancet 2000;355: Sebel P, Bowdle T, Ghoneim M, Rampil I, Padilla R, Gan T, Domino K. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 2004;99: Brice D, Hetherington R, Utting J. A simple study of awareness and dreaming during anaesthesia. Br J Anaesth 1970;42:
References

39. References
10. Bergman I, Kluger M, Short T. Awareness during general anaesthesia: a review of 81 cases from the Anaesthetic Incident Monitoring Study. Anaesthesia 2002;57: Moerman N, Bonke B, Oosting J. Awareness and recall during general anesthesia. Facts and feelings. Anesthesiology 1993;79: Leslie K, Chan M, Myles P, Forbes A, McCulloch T. Post-traumatic stress disorder in aware patients from the B-Aware Trial. Anesth Analg 2010;110:823-8.

40. References
13. Mashour GA, Kent C, Picton P, Ramachandran S, Tremper K, Turner C, Shanks A, Avidan M. Assessment of intraoperative awareness with explicit recall: a comparison of 2 methods. Anesth Analg 2013;116:
14. Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JH, Plaat F, Radcliffe JJ, Sury MR, Torevell HE, Wang M, Hainsworth J, Cook TM. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014;113:

41. References
15. Cook TM, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JH, Plaat F, Radcliffe JJ, Sury MR, Torevell HE, Wang M, Hainsworth J, Pandit JJ. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medico-legal issues. Br J Anaesth 2014;113: Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev 2014;6:Cd