Errors in veterinary anesthesia

156 Pages·2017·2.16 MB·English

by  Ludders

Errors in veterinary anesthesia
Errors in veterinary
anesthesia
John W. Ludders, DvM, DipaCvaa
Professor Emeritus, College of Veterinary Medicine,
Cornell University, Ithaca, NY, USA
Matthew McMillan, BvM&S, DipECvaa, MRCvS
Clinical Anaesthetist, Department of Veterinary Medicine,
University of Cambridge, Cambridge, UK
This edition first published 2017 © 2017 by John Wiley & Sons, Inc
Editorial Offices
1606 Golden Aspen Drive, Suites 103 and 104, Ames, Iowa 50010, USA
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, for customer services and for information about how to apply for
permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley‐blackwell.
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients,
is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center,
222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license
by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting
Service are ISBN‐13: 9781119259718/2017
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names
and product names used in this book are trade names, service marks, trademarks or registered trademarks of
their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
The contents of this work are intended to further general scientific research, understanding, and discussion only
and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis,
or treatment by health science practitioners for any particular patient. The publisher and the author make no
representations or warranties with respect to the accuracy or completeness of the contents of this work and
specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular
purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the
constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to
review and evaluate the information provided in the package insert or instructions for each medicine, equipment,
or device for, among other things, any changes in the instructions or indication of usage and for added warnings
and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or
Website is referred to in this work as a citation and/or a potential source of further information does not mean
that the author or the publisher endorses the information the organization or Website may provide or
recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may
have changed or disappeared between when this work was written and when it is read. No warranty may be
created or extended by any promotional statements for this work. Neither the publisher nor the author shall be
liable for any damages arising herefrom.
Library of Congress Cataloging‐in‐Publication Data
Names: Ludders, John W., author. | McMillan, Matthew, author.
Title: Errors in veterinary anesthesia / John W. Ludders, Matthew McMillan.
Description: Ames, Iowa : John Wiley & Sons, Inc, 2017. | Includes bibliographical references and index.
Identifiers: LCCN 2016022481| ISBN 9781119259718 (cloth) | ISBN 9781119259732 (Adobe PDF) |
ISBN 9781119259725 (epub)
Subjects: LCSH: Veterinary anesthesia. | Medical errors. | MESH: Medical Errors–veterinary |
Anesthesia–veterinary | Medical Errors–prevention & control
Classification: LCC SF914 .L77 2017 | NLM SF 914 | DDC 636.089/796–dc23
LC record available at https://lccn.loc.gov/2016022481
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be
available in electronic books.
Set in 8.5/12pt Meridien by SPi Global, Pondicherry, India
1 2017
To veterinary anesthetists who err and wonder why
Contents
Preface, ix 6 Errors of Clinical Reasoning and Decision‐making
in Veterinary Anesthesia, 71
Acknowledgments, xi
Cases, 72
Introduction, xiii
Near miss vignettes, 85
Conclusion, 87
References, 87
1 Errors: Terminology and Background, 1
Error: terminology, 1 7 Errors of Communication and Teamwork
Conclusion, 5 in Veterinary Anesthesia, 89
References, 5 Cases, 89
Near miss vignette, 95
2 Errors: Organizations, Individuals, and Unsafe Acts, 7
Conclusion, 96
Error causation: technical factors, 7
References, 97
Error causation: organizational and supervision
factors, 7 8 Error Prevention in Veterinary Anesthesia, 99
Error causation: environmental factors, 12 General strategies for error prevention, 100
Error causation: personnel factors, 12 Specific strategies for error prevention, 104
Error causation: human factors, 12 Conclusion, 119
Error causation: other factors, 22 References, 119
Conclusion, 22
Appendix A. Suggested Readings, 121
References, 22
Appendix B. Terminology, 123
3 Reporting and Analyzing Patient Safety Incidents, 25
Appendix C. ACVAA Monitoring Guidelines, 127
The limitation in only counting errors, 25
How can we learn the most from our errors?, 26 Appendix D. ACVAA Guidelines for Anesthesia
Analyzing patient safety incidents, 36 in Horses, 131
Conclusion, 43
Appendix E. A Brief History of Checklists, 133
References, 43
Appendix F. FDA Anesthesia Apparatus Checkout, 135
4 Equipment and Technical Errors in Veterinary
Appendix G. Association of Veterinary Anaesthetists
Anesthesia, 45
Anaesthetic Safety Checklist, 137
Cases, 47
Near miss vignettes, 51 Appendix H. Critical Clinical Condition Checklists, 139
Conclusion, 57
References, 58
Index, 149
5 Medication Errors in Veterinary Anesthesia, 59
Cases, 60
Near miss vignettes, 66
Conclusions, 69
References, 69
vii
Preface
It’s a busy night of emergencies. A puppy, having eaten into the endotracheal tube rather than attach it to a
its owner’s socks, is undergoing exploratory abdominal flow‐by device, a device that is small and located out of
surgery for gastrointestinal obstruction. A young tomcat sight at the other treatment bay. By inserting the insuf-
is being treated for urinary tract obstruction, and a flation hose into the endotracheal tube the patient’s
Pomeranian with a prolapsed eye has just been admitted airway is partially obstructed; the oxygen flow is set at
as has a dog with multiple lacerations from a dog fight. 5 L min−1 (Figure 1). No one notices the error because
A German shepherd with gastric dilatation and volvulus the rest of the team is focused on inserting the stomach
is being treated in one of the two bays in the emergency tube; within a few minutes the dog has a cardiac arrest.
treatment room. This evening is also a new employee’s During CPR, which is ultimately unsuccessful, the team
first night on duty; she and two other staff members are recognizes that the dog has a pneumothorax and its
assisting with the German shepherd dog. After initially source is quickly identified.
stabilizing the dog, it is anesthetized with fentanyl and Why do well‐trained and caring professionals make
propofol and then intubated so as to facilitate passing a errors such as this? How should the veterinarian in
stomach tube to decompress its stomach. The new charge of the emergency respond to this accident?
employee, who is unfamiliar with the emergency prac- How can a veterinarian or practice anticipate an error
tice’s standard operating procedures, facilities, and or accident such as this so that it can be avoided, or
equipment, is told to attach an oxygen insufflation hose prevented from occurring again? Both of us have
to the endotracheal tube. The employee inserts the hose thought about and explored the hows and whys of
Oxygen insufflation hose
Hose connection
ETT attaches here
Flow-by device
(a) (b)
Figure 1 a) Insufflation hose inserted into an endotracheal tube almost completely occluding it. b) Flow‐by device with
connector where the oxygen insufflation hose is supposed to attach. The flow‐by device is nothing more than an endotracheal
tube (ETT) adaptor with a connector normally used with a gas analyzer for sampling and analyzing airway gases from an
anesthetized, intubated animal. Using it for insufflating oxygen is a unique application of this device, not a usual one, and
probably not a familiar one for the new employee of this practice.
ix
x Preface
errors that occur during anesthesia. Based on our failings for all to see. How those of us involved in
experiences and as teachers of anesthesia to veteri- veterinary medicine, specifically those of us in doing
nary students and residents, it is our opinion that the and teaching veterinary anesthesia, can learn from
answers lie in the reality that we can and must learn errors is the purpose of this text.
from errors; they are learning opportunities, not John W. Ludders
personal or professional stigmata highlighting our Matthew McMillan
Acknowledgments
We cannot thank enough those who have supported of North Carolina‐Chapel Hill and Director of the
and encouraged us in the writing of this book. A number Consortium of Anesthesiology Patient Safety and
of colleagues kindly read various drafts of this book, and Experiential Learning, provided references and her
their comments helped us clarify initial thoughts as to thoughts concerning issues relating to effective training
how the topic of errors in veterinary anesthesia should strategies for residents. Dr Allisa Russ at the Roudebush
be approached. Most important was their encourage- Veterans Administration Medical Center and the
ment to push on with the writing. Regenstrief Institute, and who is involved in developing
Some colleagues expended a great deal of time in processes for reducing medication errors, generously
reviewing a first draft. Looking back at that draft makes shared her knowledge about human factors analysis,
us appreciate their efforts even more. Two individuals what it is and what it is not.
deserve special mention. Dr Erik Hofmeister at the John Wiley & Sons, our publisher, have also been
University of Georgia, pointed out details we came to very supportive since we first approached them. We
realize were not important to the subject matter; his were both surprised and thankful that the concept of
comments were especially helpful in structuring and writing a book about error in veterinary anesthesia,
writing what is now Chapter 2. Dr Daniel Pang at the something we feared might have been perceived as too
University of Calgary, made extensive comments much of a niche subject, was accepted in such an enthu-
throughout the draft, comments that encouraged us to siastic manner.
do a better job of using terminology consistently, and to Throughout the writing process our families have
develop concepts more thoroughly and link them more encouraged and assisted us in our efforts. In particular,
effectively to the cases we have included. our wives, Kathy (J.W.L.) and Sam (M.W.M.), have
When faced with questions about various concepts in tolerated a huge amount of inconvenience and disrup-
patient safety, concepts that are evolving as this book tion of the routines of family life. Without their
was being written, we asked for advice from individuals support, encouragement, and sacrifices this book
who are experts in various aspects of this field. We were would not have been possible. We are as always in
pleasantly surprised to find that these individual were their debt.
approachable and willing to give of their time and share Finally, as with any book there will be errors and they
their knowledge. Dr Marjorie Steigler at the University are our errors alone, we are after all only human.
xi
Introduction
Knowledge and error flow from the same mental sources, only success can tell the one from the other.
Ernst Mach, 1905
There are many veterinary anesthesia texts on how to In general there are two approaches to studying and
anesthetize a variety of animal patients; such is not the solving the problem of human fallibility and the making
purpose of this text. It does, however, have everything of errors: the person approach (also called proximate
to do with the processes involved in anesthetizing cause analysis) and the systems approach (Reason
animal patients, from pre‐anesthetic assessment to 2000). The person approach focuses on individuals and
recovery, and does so by seeking answers to how and their errors, and blames them for forgetfulness, inatten-
why errors occur during anesthesia. In this text we tion, or moral weakness. This approach sees errors aris-
define an error as a failure to carry out a planned action ing primarily from aberrant mental processes, such as
as intended (error of execution), or the use of an incor- forgetfulness, inattention, poor motivation, careless-
rect or inappropriate plan (error of planning), while an ness, negligence, and recklessness (Reason 2000). Those
adverse incident is a situation where harm has occurred who follow this approach may use countermeasures
to a patient or a healthcare provider as a result of some such as poster campaigns that appeal to people’s sense
action or event. How can those who are responsible for of fear, develop new procedures or add to existing ones,
the anesthetic management of patients detect and man- discipline the individual who made the error, threaten
age unexpected errors and accidents during anesthesia? litigation, or name, blame, and shame the individual
How can we learn from errors and accidents? who erred (Reason 2000). It’s an approach that tends to
In the heat of the moment when a patient under our treat errors as moral issues because it assumes bad
care suffers a life‐threatening injury or dies, it is natural things happen to bad people—what psychologists call
to look for something or someone to blame; usually the the “just world hypothesis” (Reason 2000).
person who “made the mistake.” This is a normal In contrast, the systems approach recognizes the
response. Subsequently we may reprimand and chastise fundamental reality that humans always have and always
the individual who caused the accident and, by so doing, will make errors, a reality we cannot change. But we can
assume we’ve identified the source of the problem and change the conditions under which people work so as to
prevented it from ever occurring again. Unfortunately, build defenses within the system, defenses designed to
such is not the case because this approach fails to take avert errors or mitigate their effects (Diller et al. 2014;
into account two realities: (1) all humans, without Reason 2000; Russ et al. 2013). Proponents of the systems
exception, make errors (Allnutt 1987); and (2) errors approach strive for a comprehensive error management
are often due to latent conditions within the organiza- program that considers the multitude of factors that lead
tion, conditions that set the stage for the error or to errors, including organizational, environmental, tech-
accident and that were present long before the person nological, and other system factors.
who erred was hired. We can either acknowledge these Some, however, have misgivings about these two
realities and take steps to learn from errors and acci- approaches as means of preventing errors in medical
dents, or we can deny them, for whatever reasons, be practice. A prevalent view is that clinicians are person-
they fear of criticism or litigation, and condemn our- ally responsible for ensuring the safe care of their patients
selves to make the same or similar errors over and over and a systems or human factors analysis approach will
again (Adams 2005; Allnutt 1987; Edmondson 2004; lead clinicians to behave irresponsibly, that is, they will
Leape 1994, 2002; Reason 2000, 2004; Woods 2005). blame errors on the system and not take personal
xiii
xiv Introduction
responsibility for their errors (Leape 2001). Dr Lucian This text consists of eight chapters. The first chapter is
Leape, an advocate of the systems approach, points out divided into two sections, the first of which briefly dis-
that these thoughts only perpetuate the culture of blame cusses terminology and the use of terms within the
that permeates healthcare (Leape 2001). The essence of domain of patient safety. The reader is strongly encour-
systems theory is that human errors are caused by aged to read the brief section on terminology because it
system failures that can be prevented by redesigning defines the terms we use throughout this book. Terms,
work environments so that it is difficult or impossible to in and of themselves, do not explain why or how errors
make errors that harm patients (Leape 2001). Leape occur; that is the purpose of the second section, which
contends that this approach does not lessen a clinician’s provides some answers to the “whys” and “hows” of
responsibility, but deepens and broadens it; when an error genesis. This discussion draws upon a large body
error does occur the clinician has a responsibility—an of literature representing the results of studies into the
obligation—to future patients to ask how the error could causes and management of errors and accidents; a body
have been prevented, thus questioning the system with of literature spanning the fields of psychology, human
all of its component parts. Leape goes on to say that fears systems engineering, medicine, and the aviation,
about “blameless” medicine are unfounded and are nuclear, and petrochemical industries. This section is
related to the universal tendency to confuse the making not an exhaustive review of the literature, but is meant
of an error with misconduct (Leape 2001). Misconduct, to acquaint the reader with error concepts and termi-
the willful intent to mislead or cause harm, is never to be nology that are the basis for understanding why and
tolerated in healthcare. Multiple studies in many differ- how errors happen.
ent types of environments including healthcare, have Terminology, especially abbreviations, can be a
shown that the majority of errors—95% or more—are source of error. In the medical literature many terms
made by well‐trained, well‐meaning, conscientious peo- are abbreviated under the assumption they are so
ple who are trying to do their job well, but who are common that their meanings are fully recognized and
caught in faulty systems that set them up to make mis- understood by all readers. For example, ECG is the
takes and who become “second victims” (Leape 2001). abbreviation for electrocardiogram unless, of course,
People do not go to work with the intent of making you are accustomed to EKG, which derives from the
errors or causing harm. German term. It is assumed that every reader know
This text is written with a bias toward the systems that “bpm” signifies “beats per minute” for heart rate.
approach, a bias that has grown out of our experiences But wait a minute! Could that abbreviation be used for
as anesthetists, as teachers of anesthesia to veterinary breaths per minute? Or, what about blood pressure
students, residents, and technicians, and as individuals monitoring? And therein is the problem. A number of
who believe in the principles and practices underlying studies have clearly shown that abbreviations, although
continuous quality improvement. This latter stance is their use is well intentioned and meant to reduce
not unique and reflects a movement toward the sys- verbiage, can be confusing, and out of that confusion
tems approach in the larger world of healthcare (Chang misunderstandings and errors arise (Brunetti 2007;
et al. 2005). Kilshaw et al. 2010; Parvaiz et al. 2008; Sinha et al.
No part of this book is written as a criticism of others. 2011). This reality has led us to avoid using abbrevia-
Far from it. Many of the errors described herein are our tions as much as possible throughout the book. In the
own or those for which we feel fully responsible. Our few instances where we do use abbreviations, primarily
desire is to understand how and why we make errors in in the chapters describing cases and near misses, we
anesthesia so as to discover how they can be prevented, spell the terms in full and include in parentheses the
or more quickly recognized and managed. We believe abbreviations that will be used in that particular case or
that the systems approach allows us to do just that. It is near miss vignette. It seems like such a minor detail in
also an approach that can be used to help teach the the realm of error prevention, but the devil is in the
principles of good anesthetic management to those details.
involved in veterinary anesthesia. This approach also The second chapter presents the multiple factors that
has broader applicability to the larger world of veteri- cause errors, including organizational, supervisory,
nary medicine. environmental, personnel, and individual factors. At