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Operation room hazards AND PATIENT SAFETY


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Operation room hazards AND PATIENT SAFETY

  2. 2. Definition • Hazard: a situation that poses a level of threat to life, health, property, or environment. • A hazard does not exist when it is not happening. • Anesthesia and surgery are conducted in technologically intense envt……potentially hazardous.
  3. 3. The most common hazards in OR • Fires and Explosion • Static Electricity • Electrical Hazards • Radiation Injury • Air Pollution and • Power Failure
  4. 4. Fires explosions • Both of these can cause death or injury to the patient. • Only occur if we have 3 things: – spark or a hot surface, – flammable substance and – source of oxygen
  5. 5. Sources of sparks or heat – Static electricity – Faulty electrical switches and apparatus, e.g. saws, plaster cutters and drills – Foreign matter, e.g. dirt or grease in the oxygen or nitrous oxide cylinders – Diathermy – Open flames. • Flammable substances: Includes ether, ethyl chloride and solution in sprits. The addition of oxygen increased flammability.
  6. 6. Static electricity 1 • Electricity present in the atm. • Occurs if two materials which conduct electricity poorly are brought into contact and then separated. • If there is friction or movement between the two, a spark is produced and a spark, of course, can produce an explosion.
  7. 7. Static electricity 2 • EX. Woolen fabrics, non-conducting rubber, and synthetic materials such as nylon. • Should be avoided in the OR, using graphite impregnated yellow coded rubber instead.
  8. 8. OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 1 • Conductor floor (Concrete or conductive rubber or plastic, placed on floors) • Avoid wool, plastic and nylon fabrics and wear cotton or other anti-static outer clothes instead. • Wear aprons of conductive rubber. • Wear anti-static boots or conductive canvas overshoes. • Maintain humidity of 60%. Static sparks are more frequent when the air is dry.
  9. 9. OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 2 • Ventilation- Anesthetic gases are heavier than air and tend to collect at ground level. • Regular inspection of electric switch & apparatus • Firefighting equipment should always be available • Smoking and open flames must be forbidden
  10. 10. Electrical hazards 1 • They may occur when patients are: – In contact with faulty electrically-operated medical equipment – Accidentally connected to electric circuits by spillage of blood or saline – Dependent on electrical equipment to replace or support vital organ functions – Exposed to fire or explosions – Undergoing treatment when safe levels of electrical energy are exceeded.
  11. 11. Electrical hazards 2 Electric shock: • When the body actually becomes part of an electrical circuit with significant current • Wiring defects, faulty equipment components and deteriorated insulation • Lack of maintenance and misuse are the usual causes.
  12. 12. Electrical hazards 3 Macroshock • Most common • occurs when the body conducts an electric current which does not pass directly through the heart. • Mild sensory stimulation@5 to 10 mA • @50 to 60mA- muscular contraction • @100mA- breathing becomes extremely difficult. • Somewhere above this level respiratory paralysis, cardiac arrest and severe burning occur.
  13. 13. Electrical hazards 4 Microshock • When very tiny currents, such as 100µA, are intentionally passed directly thru heart muscle – e.g. direct cardiac catheterization, CO measmt
  14. 14. Electrical hazards 5 • High frequency currents above 50 hertz are less likely to produce electric shock but can cause burns and interference with other devices such as pacemakers. • DC is less likely to cause VF than high frequency AC (above 50Hz) but can cause muscle contraction. • Nerve damage often occurs with high currents. • The SC may be involved by large currents passing from head to foot or from arm to arm.
  15. 15. Electrical burns and electrically initiated burns • Three types – Carbonization of skin (from burns at very high temperatures of 1,000°C) – Flame burns – Direct heating of tissues produce coagulation and necrosis at entry and exit points and associated injury in muscle and BV.
  16. 16. Electrosurgical units • Diathermy are arranged so that current from the active electrode flows through the patient and back to the generator • Don’t use electric blankets in conjunction with electro-surgery.
  17. 17. Air pollution 1 • RISKS – Spontaneous miscarriage, – Congenital abnormalities and – Liver disorders. • Waste anesthetic gases escape from: – Faulty valves – The ventilator – Poorly fitted components in the breathing circuit – Spilt anesthetic drugs – Expired gases from the spill valve of the anesthetic breathing system – Gases exhaled by the patient
  18. 18. Remedies • This pollution can be reduced by – Regular thorough inspection of all anesthetic equipment – Limit or avoid the use of inhalational gases and agents e.g., circle system, TIVA and RA – An efficient scavenging system. – Closed circuits – Anti spill devices
  19. 19. POWER FAILURE!!!
  20. 20. Power failure • Critical areas employing electrically driven equipment such as respirators (Ventilators) and dialysis machines require standby equipment (i.e. generators).
  22. 22. RISK • Risk is the potential that a chosen action will lead to a loss or an undesirable outcome. • Risk is a ubiquitous, natural part of life, because everything we do, including doing nothing, poses uncertain outcome. • Occasionally the term refer to the outcome itself (e.g., death as one risk of anesthesia).
  23. 23. Anesthesia risk and accidents • Accident is an unplanned, unexpected, and undesired event • Because there are no standard methods for assigning causality yet, no accurate estimates of the rate of adverse out-come • Errors related to AW mgt, monitoring, and sudden cardiac arrest during SA, equipment failures, or nerve injuries.
  24. 24. Adverse respiratory events • The most serious hazards in anesthesia. • Causes of death and brain damage are inadequate ventilation, esophageal intubation, and difficult ETI. • Cases in the first 2 causes were judged to have been preventable if better monitoring had been employed. • Anticipated difficult ETI- refer to better institution or surgical AW should be performed before anesthesia.
  25. 25. Failure to monitoring • An important contributor to anesthesia adverse events. • There are numerous ways in which pulse oximetry, capnometry, and automated blood pressure monitors can give false information, leading to missed or incorrect diagnoses.
  26. 26. Medication errors • The most frequent error in anesthesia, and in healthcare practice in general. • Similarity of drug names, containers, and label colors
  27. 27. Medication errors • Dosing errors related to the frequent need for individual • Error in numerical calculations when drawing and mixing drugs for bolus administration or IV infusion. • Wrong drug (e.g., among various insulin formulations) • Flushing a catheter with a solution containing another potent drug, • Confusion in the programming of infusion pumps
  28. 28. Recommendation • Read the label carefully 3 times!
  29. 29. Errors in diagnosis • Especially during the management of critical events.
  30. 30. Equipment errors and failures • Current anesthesia machines and associated technology incorporate substantial safety features. • Frequent and can occur in many ways, but rarely causes injury directly. • Equipment associated injury; it is more likely to be from misuse than from overt failure of a device.
  31. 31. lack of standard practice and unusual situations • Accidental dislodgement of ETT during transportation • Undiluted phenytoin by rapid IV infusion - refractory HN, arrhythmias, and death. • Undiluted K+ by rapid IV infusion - VF and cardiac arrest. • Neostigmine given without an antimuscarinic cause asystole/severe bradycardia and AV block, and can be fatal.
  32. 32. lack of standard practice and unusual situations • Inadvertent IV injection of LA- neurologic and cardiac toxicity, which can be fatal (especially with bupivacaine). • Air embolism during the placement or removal of central venous catheter • Limb necrosis if the tourniquet is left on the patient for a prolonged period
  33. 33. Summary of Risk Management RISK IS UBIQUITOUS RISK ASSESSMENT Stratification, prioritization and intervention
  35. 35. Enhancing patient safety 11/23/2015 OR Hazard and strategies to enhence PS 35 • Avoidance, prevention, and amelioration of adverse outcomes or injuries • Quality of care: Extent to which health services for individuals and populations increase likelihood of desired health outcomes and are consistent with current professional knowledge.
  36. 36. ………… • Patient safety is focused on prevention of injury. • Quality assurance generally deals with the broader spectrum of quality, including the success of treatments. • Risk management is focused on proactive patient safety, based on the principle that prevention of injuries via error reduction and system improvements
  37. 37. Practical elements 1 • Avoidance of unnecessary risk taking • Almost unending anticipation of what might go wrong, • Projection of actions in anticipation of failure and, above all, mindfulness • Being patient centered……..PATIENT IS ABOVE OUR EGO!
  38. 38. Practical elements 2 Maintaining vigilance: • The anesthesia provider must maintain alertness and be aware of, compensate for, and counteract the forces working against vigilance. • Fatigue and sleep deprivation are probably the most common causes of lapses in vigilance.
  39. 39. Practical elements 3 • Practice in a system of care • Teamwork • Preparation • Monitoring • Control for human factors: organized arrangement of supplies and drugs, esp labeling, and establishing and adhering to local standards.
  40. 40. Practical elements 4 • Care to keep IV cannula and monitoring cables orderly, lighting, and reducing clutter, noise, and distractions • Infection Control • Antibiotic administration in the perioperative interval reduces postoperative wound infection. • Surgical wound infection rates are increased 3-fold by hypothermia.
  41. 41. Anesthesia crisis management 11/23/2015 OR Hazard and strategies to enhence PS 41 • Seek assistance early and quickly inform others • Establish clarity of roles for each person involved in mgt. of event (event manager) • Use effective communication processes • Use resources effectively and identify what additional resource (people, supplies, equipment, transportation) are available to manage situation.
  42. 42. 11/23/2015 OR Hazard and strategies to enhence PS 42 CRISS MANAGEMENT DURING ANESTHESIA C1 Circulation Adequacy of peripheral circulation (rate, rhythm, and character of pulse). If pulse is absent (CPR) C2 Color Note saturation. Examine for evidence of central cyanosis,Pulseoximetry O1 Oxygen Check rotameter settings; ensure inspired mixture is not hypoxic. O2 Oxygen analyzer Adjust inspired oxygen concentration to 100% Check that oxygen analyzer shows a rising oxygen concentration distal to common gas outlet. V1 Ventilation Ventilate lungs by hand to assess breathing circuit integrity, airway patency, chest compliance, and air entry by “feel,” careful observation, and auscultation. Also inspect capnograph’s trace if available V2 Vaporizer Check all vaporizer filler ports, seating’s, and connections for liquid or gas leaks during pressurization of the system. Consider possibility of wrong agent being in vaporizer.
  43. 43. 43 CRISIS MANAGEMENT DURING ANESTHESIA (CONT…) E1 ETT check ET tube (if in use) Ensure no leaks or kinks or obstructions. Check capnograp, oximeter for possible endobronchial position E2 Elimination Eliminate anesthetic machine and ventilate with self-inflating (e.g., Ambu) bag with 100% R1 Review monitor Oxygen analyzer, capnograph, oximeter, blood pressure, ECG, temperature and NMJ monitor) R2 Review all other equipt Review all other equipment in contact with or relevant to patient (e.g., diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors…
  44. 44. 44 CRISIS MANAGEMENT DURING ANESTHESIA (CONT…) A Air way Check patency of non-intubated airway. Consider laryngospasm, FB, blood, gastric contents, or nasopharyngeal or bronchial secretions B Breathing Assess pattern, adequacy, and distribution of ventilation. Consider, examine, and auscultate for bronchospasm, pulmonary edema, lobar collapse, and pneumo- or hemothorax C Circulatio n Repeat evaluation of peripheral perfusion, pulse, BP, ECG, and filling pressures and any possible obstruction to venous return, raised intra thoracic pressure (e.g., inadvertent PEEP) D Drugs Review intended (unintended) drug or substance administered Consider whether problem may be a consequence of an unexpected effect, a failure of administration, or wrong dose, route, or manner of administration of drug
  45. 45. HAZARDS FOR ANASTHETISTS • Fire & explosions • Electrical accidents • Pollutions by anesthetic agents • Radiations • Infections • Incompatibilities / allergies • Stress • Chemical dependence OR
  46. 46. Infections • Physical spread-HSV,CMV • Blood borne-HIV,HBV,HCV • Air borne-Mtb
  47. 47. Infections • Blood borne diseases thro’ Needle stick injuries- HIV:0.3%, HBV:3%, HCV30% • 32% had at least 1 NSI in the preceding 12M.(only half of them took treatment). • More risk with hollow-core & large bore • NSI more in non dominated hands • NSI more during disposal of contaminated needles. • Anesthesiologists have risk for occupational infection during 30years of exposure-0.045-4.5%
  48. 48. Infections-HIV • Health care workers contribute 5% of total cases • 4% of emergency department pts are unidentified cases. • Pts considered infective if both screening (ELISA) & confirmatory (western blot, indirect fluorescent ab) tests are positive.
  49. 49. Infections-HIV • 54 reported cases of occupationally acquired HIV(1998). • 88% of them had H/O NSI • ? Quantity of inoculums- ( a case report :100-200µml of blood thro” i.v. produced HIV). • Risk for the pts- 6 cases reported.
  50. 50. Infections-HBV • Non immunized HCW- higher risks • 17.8% 0f seropositive among anesthesiologist • 30% became positive after 11 years of exposure • Disinfectants & gloves are not completely protective- viruses viable for >14 days in needles, gloves, & surfaces.
  51. 51. Infections-HCV • No immunization available • No specific treatment available • Advice: serologic monitoring for HCV & LFT 3- 6 monthly.
  52. 52. Infections Management of occupational infections. SAFE PRACTICE 1. Protective equipments 2. Washing methods 3. Disposal methods
  53. 53. Infections - CDC recommendations Universal precautions-1980 -considering as all pts, blood & body fluids are infective. Isolation precautions-1996 -2 tier recommendations 1. Standard precautions -to be followed for handling all pts as infective. 2. Transmission based precautions -for handling pts known to be / suspected of being risks.
  54. 54. Infections -CDC recommendations Transmission based precautions • Based on properties of specific pathogens • Airborne precautions [measles, varicella, Tb] -to prevent from small particles<5µm by specific filters air handling devices.- HEPA, Negative pressure environment • Droplet precautions [HBV, mycoplasma, streptococcal pharyngitis, rubella]-to prevent from large particles>5µm, keep distance>1m • Contact precautions [HAV, HSV, viral conjunctivitis]
  55. 55. Incompatibilities / Allergies Latex allergy • Type IV/ type I • Risk groups : 1. Spina bifida, 2. Urogenital abnormalities , 3. HCW, 4. Rubber factory workers.
  56. 56. Latex allergy Managements 1. Identification of risk groups 2. Use latex free objects-latex free environment 3. Tests: RAST[radio-allergo-sorbent test] SPT Sr.histamine Urinary histamine Sr.IgE Sr.compliments Sr.tryptase Tests for anaphylaxis Screening tests
  57. 57. Latex allergy Managements-drug regimens • Preoperative protocol: 1. Dipenhydramine -1mg/kg,po/iv,q 6hr at 13,7,1hr before surgery 2. Prednisolone -1mg/kg,po/iv,q 6hr at 13,7,1hr before surgery or hydro cortisone 4g/kg 3. Ranitidine - 2mg/kg po, 1mg/kg iv,q 12hr at 13,1hr before surgery • Postop protocol -drugs to be repeated for 12hrs
  58. 58. Stress • Inevitable, universal phenomenon to which no one is immune • Job related stress are unavoidable but may be controlled • 2 types-Unavoidable & Avoidable • Unavoidable-professional stress • Avoidable-sleep related
  59. 59. Stress Unavoidable Stress • Professional Stress • Co-worker relationships • Work load • Litigations • Peer review • Professional dissatisfaction • Administrative responsibilities
  60. 60. Stress Avoidable Stress • Sleep related-altered sleep pattern, sleep deprivation • Coincide with natural sleep peaks • Identification of sleep disturbances • Regulations of working hours
  61. 61. Chemical dependence Self administration of drugs & suicide rates are high among anesthesiologist. • Addiction :compulsive, continued use of drugs inspite of adverse, a chronic, relapsing condition resulting from long term effects of drugs on brain, due to molecular, structural, cellular, & functional changes. • Dependence: physical / psychological inability to control drug use • Abuse :use of drugs in detrimental way but not to the point of addiction. a pre addiction level, can easily quit. a voluntary act.
  62. 62. Chemical dependence Causes • Stress • Availabilities • Curiosity for experimentation • Drug potency • Others-genetic predisposition
  63. 63. Chemical dependence Management • Identification • Intervention • Referral • Rehabilitation
  64. 64. References 11/23/2015 OR Hazard and strategies to enhence PS 64 • Safe anesthesia –third edition • Ronald D Miller and Manuel C Pardo, Jr • Airway management in emergencies, George Kovacs and J. Adam Law, 2008 • Clinical Anesthesiology, 4th Edition, G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray • Clinical Anesthesia, 5th Edition by Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K. 2006 • Miller’s Anesthesia, 7th edition by Ronald D. Miller, 2010 • Decontamination of medical equipment, update in anesthesia content number 7, 1997