Patient Safety Guidelines for Anesthesia Care
Safe anesthesia practices are not limited to the time spent during a surgery or procedure. Safe anesthesia care begins with the preoperative assessment and continues through the postoperative period. To help you keep your patients safe and avoid liability risks, we highlight common oversights and offer suggestions for practice improvement.
Many anesthesia records include no evidence that the patient gave informed consent. Patients often testify that they do not recall their anesthesia provider discussing any risks. The frequent use of amnestics as premedication, given shortly after the preoperative interview, is one possible explanation. Often, there is no third-party witness to the interview, and the anesthesia provider will have only a written record of the informed consent process. What is surprising, however, is that many anesthesia records omit this important notation. Your documentation need not be extensive: “Discussed general anesthesia risks with patient, including sore throat, dental injury, pneumonia, and death.”
No patient entering surgery wants to hear about possible death. You can, however, phrase the risks in a reassuring light: “Anesthesia is becoming safer all the time. Death during surgery is extremely uncommon these days, but I need to mention this as a rare complication of anesthesia.” That advisory is important from a malpractice standpoint. Patients who have consented to the remote possibility of death will have difficulty arguing that they never would have had anesthesia had they known a dental crown could be loosened.
You should explain in advance to patients who have consented to regional anesthesia the possible need for general anesthesia. If a spinal wears off intraoperatively or a high block develops, you will not be able to gain a second consent from the patient—and attorneys pay extraordinary attention to the informed consent process.
Determine an informed consent procedure that you are comfortable with, and make sure to document in the record what you explain to the patient. For greater liability protection, the anesthesia provider is encouraged to use an anesthesia-specific informed consent document. This memorializes patient consent separately rather than relying on a surgical consent form for addressing anesthesia issues. Combining the anesthesia consent with the surgical consent inappropriately diminishes the importance and significance of the administration of anesthesia.
When a surgeon operates on the wrong limb or performs a procedure not listed in the surgical consent, the anesthesia provider is usually named if a malpractice case results. State laws vary as to how much legal responsibility the anesthesia provider has for surgical procedures. Still, prevention is the best defense against a malpractice claim. Active involvement in the time-out procedure to verify a patient’s identity and to check the surgical consent for the correct procedure, correct side, correct site, and correct position takes less than a minute. A time out should also occur prior to the performance of an anesthetic block, and if multiple surgeons are performing multiple procedures, a time out should take place prior to each procedure.
Taking that time can save you, the surgeon, the nurses, and the hospital a considerable amount of anguish should a discrepancy arise. Make such procedures a routine part of your preoperative checks.
Damage to natural teeth or cosmetic dental work causes many anesthesia claims. In a review of The Doctors Company closed claim data for anesthesia, dental damage is the most frequent allegation. In addition to dental damage from a traumatic intubation, damage often occurs in the recovery room when patients bite down on rigid plastic oral airways.
Dental damage claims are usually settled by paying for the dental repair work. The cost escalates markedly, however, when either the patient or the provider becomes angry. As a rule, dental injury should be mentioned as a possible risk to all patients who have consented to general anesthesia. The preanesthetic evaluation should include thorough documentation of dental condition.
As with any indication of patient dissatisfaction, notify The Doctors Company if a patient has complained of possible dental injury.
Anesthesia records are, by necessity, abbreviated and concise. That leaves little room for detailed descriptions of unusual events. If something out of the ordinary happens (e.g., anaphylaxis, respiratory arrest, cardiac arrest), it is extremely useful to have a separate narrative that details the sequence of events, documents the time as closely as possible, and records the treatment rendered. If you are ever called upon to defend your care and treatment, it is better to have a record that reads “narrow complex bradyarrhythmia unresponsive to atropine” than one that says “patient coded, resuscitation performed.” Care of the patient always comes first, and no one expects you to fill out the record during an emergency situation, but you should write the narrative, with times and dates, while events are fresh in your mind.
If you are using an electronic Anesthesia Information Management System (AIMS), the automated real-time input of vital sign data may increase the accuracy of the anesthesia record. However, a handwritten note (“free text”) about an event may still be appropriate.
When an untoward event occurs, there is a tendency to want to make sure your anesthesia record is perfect. Do not make alterations after the fact. One anesthesiologist, after a patient’s respiratory arrest, decided to rewrite his anesthesia record, so he threw the first copy into the trash. When the case became a malpractice claim, the first copy was produced by the surgery center, thereby casting doubt on the anesthesiologist’s veracity and motives. Similarly, it is unwise to chart ahead or write notes in advance. Subsequent events may not correspond to what you have written.
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