Three factors affecting anesthesia safety and malpractice in the operating room
Medical journal article reports that changing operating room medication labels can prevent mix-ups
In May 2018, the Journal of Patient Safety published an article about how label design for medications affects patient safety during an operating room (OR) crisis.
The idea behind the study is straightforward. If an operating room supply drawer contains several bags of medication that look the same, it would be easy for a physician or nurse to grab the wrong one in a high-stress emergency situation.
To prove their point, researchers recruited nearly 100 anesthesia providers who were still in training. They designed a simulation in which each participant was the sole anesthesia provider during a surgery in an operating room where the patient had an unexpected vascular injury.
In the simulation, the surgeon asked participants to administer a medication called hetastarch because of the patient’s hemodynamic (blood flow) instability. The anesthesia cart drawer contained three intravenous (IV) bags of hetastarch and one IV bag of lidocaine, with all four bags being the same size.
For some participants, the medication bag labels were redesigned to make the two drugs more easily distinguishable. For other participants, the medication bag labels were very similar. Not surprisingly, the redesigned labels helped participants correctly select hetastarch from the cart. The researchers concluded that redesigning medication labels could prevent some potentially catastrophic medication errors from reaching patients.
Anesthesia medical malpractice
As a Houston, Texas medical malpractice attorney, I have seen a flurry of cases in the last several years involving operating room errors by anesthesia providers. I certainly believe that anything that can be done to help reduce these errors would tremendously benefit patients and their safety.
There are two factors that I see over and over again that I believe contribute to medical malpractice by anesthesiologists and certified registered nurse anesthetists (CRNAs).
First, many operations and procedures are conducted in non-hospital settings, like surgical centers. In my view, surgical centers have popped up all over the place largely because surgeons and physicians are looking for new sources of revenue. Instead of letting hospitals collect the hefty operating room fees, physician-owned surgical centers allow doctors to profit.
For the many patients who experience no complications during a surgery, operation or procedure, surgical centers work out fine. When something goes wrong, though, that is a different story. Surgical centers are simply not equipped to handle an operating room emergency as capably as hospitals are.
For example, I am currently working on a medical malpractice case in Houston involving the death of a patient in his 40s from a cardiovascular event that happened during a routine shoulder surgery. The surgeon told the patient that he would perform the procedure at a surgical center. As we conduct discovery in the lawsuit, I am sure that we will find that the surgeon owns at least part of the surgical center.
When the patient stopped breathing in the operating room, the anesthesiologist tried to resuscitate him, but was unsuccessful. The surgical center rushed to call 911 to request an ambulance to take the patient to a hospital. By the time he arrived at the hospital, though, it was too late. I believe that the outcome may have been different if he had been in a hospital operating room, instead, when he stopped breathing.
Second, the overall way that anesthesia services are provided has changed. Anesthesiologists are medical doctors with advanced training on how to administer anesthetic medications and handle medical emergencies.
Certified registered nurse anesthetists (CRNAs) also provide anesthesia services. CRNAs are registered nurses with additional training in providing anesthesia; however, they have nowhere near the knowledge and training of a board-certified anesthesiologist.
Largely as a cost-saving measure, many states, including Texas, have allowed CRNAs to provide anesthesia services with an extensive amount of independence. In Texas, CRNAs still must be medically directed or supervised by an anesthesiologist, which means that there must be collaboration on the anesthesia care plan, as well as induction (placing the patient under anesthesia) and emergence (bring the patient out of anesthesia). In addition, the anesthesiologist is supposed to be immediately available if something goes wrong. Other than these limitations, CRNAs enjoy substantial autonomy in their practices.
In my experience, the fact that a nurse anesthetist, rather than an anesthesiologist, will be overseeing anesthesia services in the operating room is seldom disclosed to a patient during the informed consent process. Sometimes, an anesthesiologist physician will visit with the patient before the procedure to obtain informed consent. That anesthesiologist, though, will not be the one handling the anesthesia, but will rather be down the hall somewhere during the surgery.
In many facilities, anesthesiologists are relegated to medically directing or supervising four or more CRNAs who are providing anesthesia services to patients in four different operating rooms at once. If something goes wrong in one of the operating rooms, they call the anesthesiologist. What happens if there is a problem with two patients at once?
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine