Quality and Safety in Anaesthesia

Quick Answer

Patient safety is a core competency for anaesthetists. Human factors: Understanding how humans interact with systems, equipment, and each other; human error inevitable, systems must be designed to prevent or catch errors ("to err is human"). Error types: Slips (execution failure), lapses (memory failure), mistakes (planning failure), violations (deliberate deviation). Safety culture: Just culture (balances learning from error with accountability), reporting culture (near misses reported without fear), learning culture (continuous improvement). Quality improvement: Audit (systematic review against standards), PDSA cycles (Plan-Do-Study-Act), clinical indicators (mortality, morbidity), morbidity and mortality meetings (M&M). ANZCA safety initiatives: Guidelines (PS series), standards (monitoring, equipment), incident reporting (AIRS), closed claims analysis (learning from litigation). Never events: Wrong patient/procedure/site, retained foreign object, airway fire. Checklists: WHO Surgical Safety Checklist (sign-in, time-out, sign-out), anaesthetic checklist. Crisis management: Closed-loop communication, shared mental model, allocation of tasks, CICO (Can't Intubate, Can't Oxygenate) protocol. [1-10]

Human Factors and Error

Understanding Human Error

Types of Error:

1. Slips (Execution Failures):

• Correct plan but wrong execution
• Example: Intending to draw up fentanyl but drawing up midazolam (look-alike vials)
• Causes: Distraction, fatigue, poor design, automaticity

2. Lapses (Memory Failures):

• Forget to carry out intended action
• Example: Forgetting to turn on oxygen after changing cylinder
• Causes: Interruptions, time pressure, competing demands

3. Mistakes (Planning Failures):

• Wrong plan
• Example: Giving suxamethonium to patient with burns >48 hours old (hyperkalemia)
• Causes: Lack of knowledge, poor judgment, inexperience

4. Violations (Deliberate Deviations):

• Conscious deviation from rules/procedures
• Example: Proceeding with emergency surgery without full preoperative assessment
• Types:
• Routine (corner-cutting normalized)
• Situational (pressure of circumstances)
• Exceptional (emergency necessity)

Swiss Cheese Model (Reason)

Concept:

• Defenses against hazards are like slices of Swiss cheese
• Each slice has holes (weaknesses)
• Accidents occur when holes in multiple slices align
• No single defense perfect; need multiple layers

Application:

• Drug checking: Read label (layer 1), double-check with colleague (layer 2), barcode scanning (layer 3)
• Airway management: Preoperative assessment (layer 1), equipment check (layer 2), difficult airway trolley (layer 3), CICO protocol (layer 4)

Systems Approach to Safety

Key Principle:

• Individual blame counterproductive
• System must be designed to prevent or catch errors
• "To err is human"
• Focus on "what went wrong" not "who is to blame"

Safety Defenses:

1. Design: Equipment and processes that prevent error (fail-safes, interlocks)
2. Barriers: Physical or procedural barriers (checklists, double-checks)
3. Redundancy: Multiple layers of protection
4. Recovery: Detection and mitigation of errors before harm

Safety Culture

Components of Safety Culture

1. Reporting Culture:

• Encourage reporting of near misses and errors
• No-blame or just culture (not punitive)
• Learn from incidents
• ANZCA AIRS (Anaesthesia Incident Reporting System)

2. Just Culture:

• Balance between learning and accountability
• Not punished: Honest error, slips, lapses
• Addressed: Recklessness, intentional violations, incompetence
• Questions asked: Was behavior reckless? Was training adequate? Were systems supportive?

3. Learning Culture:

• Continuous improvement
• Evidence-based practice
• M&M meetings
• Audit and feedback

4. Flexible Culture:

• Adapt to changing demands
• Hierarchy flattened during crisis
• Speaking up encouraged

Creating a Safety Culture

Leadership:

• Model safe behavior
• Prioritize safety over production
• Allocate resources for safety
• Non-punitive response to errors

Teamwork:

• Flatten hierarchy (speak up, challenge)
• Closed-loop communication
• Shared mental model
• Briefings and debriefings

Quality Improvement

Audit vs Research

Audit:

• Purpose: Compare practice against standard
• Questions: "Are we doing what we should be doing?"
• Cycle: Continuous
• Outcome: Improvement
• Ethics: Not required (quality improvement)

Research:

• Purpose: Generate new knowledge
• Questions: "What is the best thing to do?"
• Outcome: Knowledge
• Ethics: HREC approval required

Audit Cycle

1. Identify Problem:

• Morbidity data
• Incident reports
• Clinical observation

2. Define Standard:

• Guidelines (ANZCA, ASA, etc.)
• Literature evidence
• Expert consensus

3. Measure Practice:

• Data collection
• Sample size calculation

4. Compare to Standard:

• Gap analysis
• Identify areas for improvement

5. Implement Change:

• Education
• Protocol development
• System redesign

6. Re-audit:

• Measure again
• Has practice improved?

PDSA Cycles

Plan:

• Hypothesis about change
• Plan intervention

Do:

• Implement on small scale
• Collect data

Study:

• Analyze results
• Did change work?

Act:

• Adopt, adapt, or abandon
• Scale up if successful

Clinical Indicators

Structure Indicators:

• Presence of equipment, personnel, protocols
• Example: Availability of difficult airway trolley

Process Indicators:

• What was done for patient
• Example: Antibiotic prophylaxis within 60 minutes of incision

Outcome Indicators:

• Results of care
• Example: Mortality rate, surgical site infection rate

Balanced Scorecard:

• Multiple dimensions: Clinical, financial, patient satisfaction, learning

Morbidity and Mortality (M&M) Meetings

Purpose:

• Review complications and deaths
• Educational
• Identify system issues
• Peer support

Format:

• Case presentation
• Discussion of factors
• What could have been done differently?
• Action items (system improvements)

Confidentiality:

• Protected peer review in many jurisdictions
• Learning environment, not punitive

ANZCA Safety Initiatives

Professional Standards (PS Series)

Key Guidelines:

• PS04: Fast-tracking from OR to ward
• PS08: Delegation of tasks to unregistered personnel
• PS18: Billing, fees, financial records
• PS21: Sedation for procedures
• PS22: Regional anaesthesia
• PS42: Paediatric anaesthesia
• PS45: Transport and positioning
• PS48: Anaesthesia care of severely injured
• PS54: Cardiopulmonary bypass
• PS55: Monitoring during anaesthesia

Purpose:

• Minimum standards
• Risk mitigation
• Professional accountability

Standards and Guidelines

Monitoring Standards (PS55):

• Required: ECG, SpO₂, EtCO₂, BP (cycling or continuous), temperature
• Recommended: Neuromuscular monitoring, BIS/depth monitoring for TIVA

Equipment Standards:

• ANZCA-ASA standards for anaesthetic machines
• Oxygen supply, backup systems
• Alarms and monitors
• Breathing systems

Clinical Practice Guidelines:

• Evidence-based recommendations
• Regular review and update

Incident Reporting

AIRS (Anaesthesia Incident Reporting System):

• Voluntary: De-identified incident reporting
• Purpose: Learning, not punishment
• Types: Near misses, no harm, harm
• Analysis: Trend analysis, hazard identification
• **Feedback": Safety alerts, newsletter

State-based Systems:

• VIC: VIC ANS
• NSW: AN-TRACE
• QLD: Qld-AN
• National: AIRS

Reporting Encouraged:

• Near misses (learning gold)
• Equipment failures
• Medication errors
• Unexpected outcomes

Closed Claims Analysis

Concept:

• Analysis of litigation claims
• Learning from expensive mistakes
• Systematic review of cases

Findings (Common Themes):

• Airway: Most common, severe outcomes
• Regional: Nerve injury, wrong route
• Medication: Syringe swaps, dosing errors
• Monitoring: Failure to detect
• Equipment: Misuse, malfunction

Prevention:

• Checklists
• Monitoring standards
• Education
• System improvements

High-Risk Scenarios

Never Events

Definition:

• Serious, largely preventable patient safety incidents
• Should never happen if appropriate preventative measures taken

ANAESTHESIA-RELATED NEVER EVENTS:

1. Wrong patient, procedure, or site
2. Retained foreign object
3. Airway fire during surgery
4. Medication error causing death or severe harm

Prevention:

• WHO Surgical Safety Checklist
• Time-out procedures
• Equipment counts (swabs, instruments)
• Fire risk protocol (high FiO₂ + ignition source + fuel)

Crisis Management

Crisis Resource Management (CRM):

• Leadership: Clear leader, allocation of tasks
• Communication: Closed-loop, clear, calm
• Shared mental model: Everyone understands situation and plan
• Resources: Mobilize equipment, personnel
• Fixation error: Avoid focusing on wrong problem

Closed-Loop Communication:

• Speaker: Clear, specific, uses name
• Listener: Acknowledges, repeats back
• Confirm: Speaker confirms correct
• Example: "John, give 100 mg suxamethonium." → "Giving 100 mg suxamethonium." → "Correct, thank you."

Two-Challenge Rule:

• If concern about safety, speak up
• First challenge: Express concern
• Second challenge: If ignored, escalate
• "CUS" words: "I'm Concerned, this is Unsafe, this is a Safety issue, Stop"

CICO (Can't Intubate, Can't Oxygenate):

• Recognition: Failed intubation + failed ventilation (SpO₂ falling)
• Protocol:
  1. Call for help early
  2. Optimize attempts (position, adjuncts)
  3. Supraglottic airway
  4. If SGA fails and SpO₂ <90%: Emergency front-of-neck access
  5. Scalpel cricothyroidotomy or cannula cricothyroidotomy

Medication Safety

High-Risk Medications in Anaesthesia:

• Heparin, insulin, local anaesthetics (LAST), concentrated electrolytes, opioids

Safety Strategies:

• Standard concentrations: Reduce dosing errors
• Labeling: Clear, tall-man lettering (suxaMETHonium, suPANtronium)
• Barcoding: Technology to verify right drug
• Double-check: High-risk drugs
• Storage: Separate look-alike drugs

Syringe Labels:

• Mandatory ANZCA labeling standard
• Color-coded (blue = local anaesthetic, red = induction agent, etc.)
• Pre-printed preferred over handwritten

Safety in Indigenous Health

Aboriginal and Torres Strait Islander Safety

Cultural Safety:

• Respect and cultural understanding prevents safety issues
• Communication failures major cause of adverse events
• Family involvement in care decisions
• Interpreters when needed

Access and Equity:

• Geographic barriers delay care
• Cultural safety improves engagement
• Remote area nursing/retrieval systems

Māori Health Safety

Whānau-Centered Care:

• Family as partners in safety
• Cultural advisors to prevent misunderstandings
• Communication in culturally appropriate ways

ANZCA Final Exam Focus

SAQ Patterns

Common Questions:

• "Describe the characteristics of a safety culture."
• "What are the differences between slips, lapses, and mistakes?"
• "Explain the Swiss cheese model of accident causation."
• "How would you investigate a critical incident in your department?"

Marking Scheme Priorities:

• Safety culture components (reporting, just, learning, flexible)
• Human error types (slips, lapses, mistakes, violations)
• Systems approach (Swiss cheese model, multiple defenses)
• Quality improvement methods (audit, PDSA)
• Crisis management (CRM, closed-loop communication)

Viva Scenarios

Scenario 1: Medication Error

• Patient received wrong drug during anaesthesia
• Apply just culture: Not punitive, learn from system failures
• Investigate: Why did error occur? System redesign?
• Support staff involved

Scenario 2: Safety Culture Assessment

• Low reporting of near misses in department
• Strategies to improve: Leadership, non-punitive response, feedback
• Implement AIRS
• Regular M&M meetings

Scenario 3: Crisis Management

• CICO situation during rapid sequence induction
• Call for help, optimize attempts, SGA, front-of-neck access if needed
• Closed-loop communication
• Allocate tasks to team members

Key Points for Examination Success

1. Error types: Slips (execution), lapses (memory), mistakes (planning), violations (deliberate)
2. Swiss cheese model: Multiple defensive layers with holes; accident when holes align
3. Safety culture: Reporting, just (balance learning with accountability), learning, flexible
4. Quality improvement: Audit cycle, PDSA, clinical indicators
5. Never events: Should never happen with proper prevention (wrong site, retained foreign body, airway fire)
6. Crisis management: CRM, closed-loop communication, shared mental model, call for help early
7. Just culture: Not punished for honest errors, but address recklessness
8. ANZCA PS series: Professional standards for safety
9. AIRS: Voluntary incident reporting system
10. Human factors: Design systems to prevent/catch errors, don't rely on human perfection

References

1. ANZCA. Guidelines on Safety Culture. 2020.
2. Reason J. Human Error. Cambridge University Press; 1990.
3. Pronovost PJ et al. Creating a culture of safety. In: Making Health Care Safer II. AHRQ; 2013.
4. World Health Organization. Patient Safety Curriculum Guide. 2011.
5. ANZCA. AIRS (Anaesthesia Incident Reporting System). Available at: anzca.edu.au
6. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2017.
7. Gawande A. The Checklist Manifesto. Metropolitan Books; 2009.
8. Dekker SWA. Just Culture: Balancing Safety and Accountability. Ashgate; 2012.