1. Effective methods for preventing and managing anaesthetic incidents Adjunct Professor Martin D. Culwick Australian and New Zealand Tripartite Anaesthetic Data Committee Royal Brisbane & Women’s Hospital

2. Preventing Errors Current Methods ◦ Report Incident Locally ◦ Hold Morbidity & Mortality meetings +/- RCA ◦ Local guidelines and education process ◦ Report to WebAIRS Registry ◦ Guidelines and Publications from ANZCA, ASA & NZSA ◦ Publish in Anaesthesia and Intensive Care ◦ Education ◦ Simulation Will this eliminate Errors? (1) Yes (2) No (3) Not Sure

3. Errors – Main Categories

4. Qual Saf Health Care. 2010 Dec;19(6):e63. Epub 2010 Jul 29. System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee. Taitz J, Genn K, Brooks V, Ross D, Ryan K, Shumack B, Burrell T, Kennedy P; NSW RCA Review Committee. Source: Clinical Excellence Commission, Martin Place, Sydney, New South Wales, Australia. jonny.taitz@sesiahs.health.nsw.gov.au Abstract BACKGROUND: Preventable errors are common in healthcare. Over the last decade, Root Cause Analysis (RCA) has become a key tool for healthcare services to investigate adverse events and try to prevent them from happening again. The purpose of this paper is to highlight the work of the New South Wales (NSW) RCA Review Committee. The benefits of correctly classifying, aggregating and disseminating RCA data to clinicians will be discussed. In NSW, we perform an average of 500 RCAs per year. It is estimated that each RCA takes between 20 and 90 h to perform. In 2007, the NSW Clinical Excellence Commission (CEC) and the Quality and Safety Branch at the Department of Health constituted an RCA review committee. 445 RCAs were reviewed by the committee in 14 months. 41 RCAs were related to errors in managing acute coronary syndrome. RESULTS AND DISCUSSION: The large number of RCAs has enabled the committee to identify emerging themes and to aggregate the information about underlying human (staff), patient and system factors. The committee has developed a taxonomy based on previous work done within health and aviation and assesses each RCA against this set of criteria. The effectiveness of recommendations made by RCA teams requires further review. There has been conjecture that staff do not feel empowered to articulate root causes which are beyond the capacity of the local service to address. CONCLUSION: Given the number of hours per RCA, it seems a shame that the final output of the process may not in fact achieve the desired patient safety improvements. Downloaded 8/5/11 from http://www.ncbi.nlm.nih.gov/pubmed/20671073?dopt=AbstractPlushttp://www.ncbi.nlm.nih.gov/pubmed/20671073?dopt=AbstractPlus

6. Factors: Wrong Dose – Overdose Accidentally giving the wrong dose ◦ Paediatric ◦ Injecting whole syringe ◦ Combination with Syringe swap Syringe driver programming error ◦ mg/kg/min instead of mcg/kg/min ◦ Propofol TCI versus Remi TCI Dilution error

7. Factors with Insulin Dilution Unfamiliarity Inexperience with making up an insulin syringe Presentation of insulin From presentation: Prime Suspects – Dr.Genevieve Goulding 2011 Anaesthetic drugs are expressed as dose/ampoule e.g. fentanyl 100mcg in 2 mls Error is to assume that the insulin ampoule is 100 units in 10mls Two person check not performed prior to dilution

8. Factors with Insulin Why 1000u/10 mls? Why labelled 100u/ml Designed for s.c. use by a trained person Usually self administered Usually use insulin syringe marked in units

9. How to fix this problem ? Fix it once ? Fix it twice ? Fix it multiple times ? How many times? Current Status: Fix Once Actual status: Fixing multiple times Evidence is that “Fix Once” has temporary and local effectiveness for this particular problem

10. Fix everything two ways Technical support – software Programmers take to calls ◦ Immediate workaround ◦ Fix the software Cost ◦ Normal tech support $10/call ◦ Programmer $50/call ◦ Normal tech $10 x hundreds of calls with no permanent fix Joel Spolsky - Seven steps to remarkable customer service http://www.joelonsoftware.com/articles/customerservice.htm

11. Fix it two ways Insulin Dilution 1. Tell everyone to be careful ◦ Next M & M meeting ◦ Every change of junior staff ◦ Have a written guideline with instructions ◦ Two person check ◦ Monitor blood glucose in diabetics 2. What to do for the second way ? ◦ Pharmacy to pre-prepare the infusions ◦ Change the ampoule ◦ Improve labelling

12. Insulin dilution

13. From presentation: Prime Suspects – Dr.Genevieve Goulding 2011

14. Insulin dilution From presentation: Prime Suspects – Dr.Genevieve Goulding 2011

15. Other examples of two ways Checklists + targeted education Change of environment Equipment change Workflow and process redesign

16. Management Algorithms Acronyms Crisis Manual On line reference tool ◦ Smart Phone ◦ Tablet ◦ Notebook ◦ Desktop

17. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

18. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

19. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

20. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

21. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

22. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

23. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

24. WebAIRS – Incident Knowledge Base (in development) Screenshot from demonstration program (not approved for release)

25. Conclusion Build a safety culture Promote anaesthetic incident recording Implement safety solutions to prevent harm Fix it Twice (Peer reviewed article later this year) On line knowledge base to assist with incident management