VOLUME 26, ISSUE 2
Priscilla J. Garcia, MD, MHA Pediatrics Editor
WAKING UP SAFE AFTER PEDIATRIC ANESTHESIA
Quality improvement initiatives to improve patient safety have become a priority at many health care institutions. While it may seem as if this is a relatively new phenomenon, this work has been ongoing for several decades. In the 1970s, Cooper etx al, looked at critical incidents in anesthesia and tried to develop a systematic approach to analyzing errors, learning from them, and then modifying anesthetic technique through educationi. The American Society of Anesthesiologists Closed Claims Study has allowed investigators to access malpractice cases to analyze technique and find errors that may have contributed to harm with findings published for other anesthesiologists to learn. The Perioperative Cardiac Arrest (POCA) project started in 1997 as a voluntary registry of pediatric cardiac arrest. Observations noted in the registry led to the demise of halothane, the switch to sevoflurane, and a decrease in cardiac arrests in pediatric anesthesiaii. In 2006, the Quality and Safety Committee of the Society for Pediatric Anesthesia initiated a quality improvement project that led to the development of Wake Up Safe (WUS). WUS is a patient safety multi-institutional program that maintains a registry of de-identified, serious adverse events (SAE) with the goal of improving the quality and safety of anesthetic care provided to pediatric patients.
Data provided by WUS’ 24 – member institutions not only provides the denominator for determining the incidence of SAE but also undergoes review so as to address the cause of the event and help devise a strategy to reduce or prevent the adverse event in the future. WUS categories of SAEs that occur during an anesthetic or within 24 hours of the end of anesthesia include death; cardiac arrest; acute lung injury; acute cardiovascular deterioration; musculoskeletal injury; skin, bone, brain, spinal cord, nerve, or eye injury; surgery on the wrong body part; surgery on the wrong patient; fire; awareness under anesthesia; and medication erroriii. Each member institution has a committee of at least 3 anesthesiologists not directly involved in the SAE who conduct a root cause analysis of the event and develop an action plan for improvementiii. Since data started being collected in 2010, an average of 1.4 serious adverse events per 1000 anesthetics have been reported, which is similar to prior reportsiv.
Respiratory events have been the most common SAE and often arise from complete airway obstruction treated successfully before progressing to cardiac arrestiv. The next most common events in decreasing order are cardiac arrest, care escalation, and cardiac events. Care escalation events are those that result in unplanned hospital or ICU admissions. These events arose from medication errors (65%), equipment dysfunction (24%), blood reactions (9%), malignant hyperthermia (1%), and operating room fire (1%)iv. WUS has published advisories to the pediatric community regarding the following SAEs:
Advisory on hyperkalemic cardiac arrest after cardiovascular changes after large-volume intraoperative red blood cell transfusion (4 cases).
Advisory on preventing wrong-sided procedures (5 cases).
Advisory on decreasing the risk of intravenous medication errors. These errors included the incorrect drug being administered, the incorrect dose, an incorrect route, omission of a medication, or a medication reactioniv (23 cases).
