Yearbook of Anesthesiology-9 Raminder Sehgal, Anjan Trikha
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
Abdominal compartment syndrome 117
Abdominal distension 126
Abdominal examination 126
Abnormal maternal-fetal antigen-antibody reaction 37
Acarbose 231
Acclimatization 323
leads 314
period of 318
Acetaminophen 391
Acetazolamide 324
Acetylcholine 157
Acidosis 117
Acinetobacter 332, 340
Acromioclavicular joint 354, 356
Acromion process 355, 356
Active warming mechanisms 198
Acute coronary syndrome 216, 319
Acute high-altitude illness 308, 310
Acute hypoxemic respiratory failure 281
Acute mountain sickness 308
Acute respiratory
distress syndrome 122
failure, treatment of 174
Adaptive support ventilation 179
Adipocyte 70
subcutaneous 70
Adjunctive therapy 122
Adjustable pressure limiting valve 346
Adrenergic receptors 366
Adrenocorticotropic hormone 228
Afferent thermal sensing 191
Agitation 372, 391
blower 329
compressor 329
engineers 330
emboli, retrograde ascent of 101
handling unit 329
hunger 309
lock phenomenon 102
sampling 346
warming appliance 332
particles 340
pathogenic agents 149
Airway 40, 71
compromise, surgery for 287
manipulation 277
obstruction 58, 79
trauma, risk of 294
Alarm fatigue 155
Albumin levels 126
Alfentanil 168, 193
Allergies 146, 149
Alpha glucosidase 231
Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid 157
Alveolar anesthetic concentration 365
Alzheimer's disease 27
American Academy of Orthopaedic Surgeons 206
American Association of Clinical Endocrinologists 234, 237
American Association of Nurse Anesthesiologist 151
American College of Obstetricians and Gynecologists 70, 166
American College of Physicians 234, 237
American Diabetes Association 226, 230, 234
Consensus Statement on Inpatient Glycemic Control 237
American Heart Association 219, 378
American National Standards Institute 330
American National Surgical Quality Improvement Program 28
American Society for Parenteral and Enteral Nutrition 116
American Society of Anesthesiologists 31, 87, 92, 150, 196, 221, 247
American Society of Heating Refrigerating 330
American Society of Interventional Pain Physicians 209
Amino acid 121
glutamine 123
Analgesia 250
neuraxial 71
Anaphylactic reactions 368
Anaphylaxis 59, 60, 368
severe 368
Anemia 87, 221
Anesthesia 4, 88, 248, 363
considerations 272
devices 345
disinfection of 348
effect of 157
equipment 341, 345
for cesarean section 77
for labor 71
for neurovascular procedures 256
indications in 284
induction of 79, 264
inhalational 293
local infiltration 249
maintenance of 267
medication errors in 10
neuraxial 193
obstetric 288
practice of 10
procedures in 284
types of 227
work area 347
bacterial contamination of 137
health hazards for 145
agents, mechanism of action of 158t
drugs 29, 228
machine, alarms on 8
management 47
practice 13
technique 29
workforce, large proportion of 150
Aneurysm 256
common site of 257
development of 257
endovascular management of 266
posterior circulation 259
rupture 257, 258, 266
intraoperative 266
site of 257, 259
Angiography 219
coronary 215
intraoperative 265
pre-embolization 272f
Angiotensin-converting enzyme inhibitors 220
Anterior cruciate ligament 209
Antiangiogenic proteins 38
Antibiotic prophylaxis 346
Anticholinesterase inhibitors 55
Anticipate 70
Anticoagulation 268
myth of 60
Antihypertensives 50
Antioxidant 123
therapy 40
Apnea 164
Apoptosis 165
causation of 366
ventricular 215
Arterial air embolism 101
Arterial blood 312
gas analysis reveals 104
oxygen saturation of 309
pressure 258
Arterial gas embolism 104
Arterial oxygen saturation 181
Arterial waveform-derived cardiac output 219
Arteriovenous malformation 256, 268, 273
clinical features 270
diagnosis 271
grading of 269
incidence 269
management strategies 271
radio intervention 271
surgical excision of brain 271
with elevated risk of bleeding and rebleeding 270
anterior communicating 259
posterior communicating 259
Arthritis 25
Arthroscopy 357
and development, risk of 120
prophylaxis 49
Aspirin 250
therapy 39
Associations of Perioperative Registered Nurses 345
Atelectasis 58, 79
Atopy 149
Atrial septal defects 316
Atropine 228
Attention-deficit disorder 162
Australia and New Zealand College of Anaesthesia 12
Automated external defibrillators 134
Automatic tube compensation 177, 178
Autonomic instability 372
Awake fiberoptic intubation 286
Axilla 340
Axillary nerve 354, 355, 356, 359
anterior approach 359
inferior axilla 359
posterior approach 359
Back pain, low 206, 207
angioplasty 261
tipped blocker 294
Barbiturates 158
Barometric pressures, ambient 100
Baroreceptor reflex 229
Basal skull fracture 281
Bayley developmental scale 164
Benzodiazepines 92, 93, 158
use of 153
Benzylisoquinolinium fumarate diester 62
Beta-blockers 229
Biguanides 231
Biliary cirrhosis, primary 111
Biomarkers 93, 218
Biomedical waste 347
Biphasic positive airway pressure 80
trauma 72
weight, low 161
Blind approach 301
Blood 136, 314
brain barrier 370
glucose 226, 227, 228, 235, 235t, 240
concentrations 237t
levels 235
pressure 181
control of 43
diastolic 35, 36
management 261
non-invasive 50
systolic 35, 36, 175, 261
sugar 239
levels 227
embolic obstruction of 101
results 101
Bloodstream infection 122
fluids, discoloration of 371
mass index 39, 69, 122
average 286
temperature, monitoring of 192
Bone loss 247
Bowel obstruction 117
Brachial plexus
block 358
costoclavicular 358
infraclavicular 359
retroclavicular 359
branches of 354f
cords 360
posterior cord 354
Bradycardia 102
natriuretic peptide 319
neurotransmitters in 157
relaxation 265
Breath, shortness of 371
Bronchial cuff of right-sided double-lumen tubes, modification of 299f
Bronchoconstriction 182
Bronchoscope, pediatric 294
Bronchospasm 62
B-type natriuretic peptide 185
Calabadion 63
Calcium 30, 128
channel blockers 391
deficiency 38
supplementation 40
Capnography 111
Carbon dioxide 99, 111, 279
arterial pressure of 309
breathed out, volume of 118
high partial pressure of 104
partial pressure of 74, 312
Cardiac depression, toxicity-induced 371
Cardiac diseases 378
Cardiac index 27
Cardiac ion channel dysfunction 371
Cardiac ischemic symptoms 215
Cardiac pathology, absence of 182
Cardiac surgery 238, 366, 372
Cardiac system 182
Cardiogenic acute pulmonary edema 283
Cardiomyopathy 72
Cardiopulmonary disease 378
Cardiovascular collapse 102
Cardiovascular disease 87
Cardiovascular drug poisoning 369
Cardiovascular manifestations 40
Cardiovascular system 27, 75, 260
Carlens tube with carinal hook 295f
Catecholamines 366
Central laboratory device 238
Central nervous system 36, 103, 256, 260, 391
disorders 161
manifestations 41
Central respiratory drive 176
Central venous catheter 106, 110
placement 221
circulation 313
edema 108
high-altitude 308
irritation 41
ischemia, delayed 260
oxygen delivery 313
perfusion 108
pressure 261, 262
salt wasting syndrome 261
vasospasm, balloon angioplasty of 273
veins 101
vessels 104
Cerebrospinal fluid 77, 195
drain, opening of 258
Cerebrovascular accidents 226
Certified Registered Nurse Anesthetists 151
spine 100
superficial plexus 357
Cesarean delivery 71, 109
Challenging several traditional imaging techniques 135
Charge acidic groups 55
computerized tomography of 319
radiography 319
Chlorine, replacement of 62
Cholecalciferol 30
Chronic mountain sickness 308
Chronic obstructive pulmonary disease 178, 279
Chronic pain 87
management of 203
Circadian rhythm 191
Circle of Willis 257f, 258
Circulation 313
Cisatracurium 13
Claustrophobia 280
Clonus 372
Coagulation 268
profile 263
Cold ambient temperatures 316
consolidation 182
prevention of 304
Coma 372
Complete blood count 89, 263
Compliance rate oxygenation and pressure index 176, 177
Comprehensive geriatric assessment 28
Computer-aided decision-making system and electronic reminders 333
Confusion 372
assessment method 90
Continuous femoral nerve blocks 248
Continuous positive airway pressure 72, 177, 279, 293, 321
Continuous subcutaneous insulin infusion 232, 233
hormonal 61
use 61
Coracoid process 355, 356
Coronary artery 104
bypass grafting 367
disease 217, 247
revascularization prophylaxis trial 220
Corticosteroid, role of 185
Costoclavicular block 357
Cranial nerve deficit 259
C-reactive protein 93
Cricoid pressure 75
Critical care units 153
Cyanosis, central 317
Cyclic guanosine monophosphate 364
degradation of 322
Cyclooxygenase 250
inhibition 391
Cysteine 63
Cytochrome p450 370
Danish Birth Cohort Study 162
Daycare arthroplasty 244
Daycare surgery 238
bane of 85
context of 85
Daycare total joint arthroplasty 245
Deep breathing exercises 80
Deep venous thrombosis 250
prophylaxis 250
risk of 73
Deficit accumulation 23, 24
Degenerative diseases 203
Dehydroepiandrosterone 30
Delirium 86, 88
elderly at-risk instrument 92t
features of 86
precipitate 86
preventing 93t
risk factors for 94
screening 89
Delivery, timing of 42b
Dementia 27, 91, 95
Depression 91
Desflurane 158
Dexamethasone 322, 324
mechanism of action of 322
Dexmedetomidine 158, 167, 193
Dextrose 121
Diabetes 87
Control and Complications Trial 227
gestational 72
mellitus 25, 71, 75, 226
Diaphoresis 372
Diarrhea 117
Diazepam 160
Digital subtraction angiography 263
Dipeptidyl peptidase-4 232
Disinfection 341
levels of 345
low-level 345
Disseminated intravascular coagulation 41, 42, 46
Distractions 137
issues of 141
source of 138
Distress 215
Dizziness 310, 391
Dopamine 157
receptor antagonists 391
Double-lumen airway 300
Double-lumen endotracheal tubes 293, 296, 299, 304, 305
Double-lumen tubes
history of 295
left-sided 301
recent advances in 303
right-sided 298f
use of 294
Drowsiness 391
Drug errors, classification of 14t
Duchenne-Muscular dystrophy 58
Duke activity status index 378
Dysglycemia 226
Dysphagia postextubation, detection of 126
Dyspnea 287, 317
Eclampsia 34, 36
treatment of 46
subclinical pulmonary 319
subglottic 40
Edmonton frail scale 24
Ejection fraction 27
Electric blanket 198
Electrocardiogram 182, 260, 319
Electrocardiographic changes 106, 215, 218
Electrocardiography 134
Electroencephalogram 357
delta waves on 87
like sodium, concentration of 126
monitoring 125
Electronic data, application of 333
Electronic medical records 135
Elevated pulmonary artery wedge pressure 219
Elevated serum transaminases 36
Embolism 111
Emphasis 1
Employ regional anesthesia techniques 383
Encephalopathy, ifosfamide-induced 369
Endocannabinoids 157
abnormalities 183
function 70
Endometritis 73
Endorphins 157
Endothelial nitric oxide 314
Endotracheal tube, removal of 174
Endovascular therapy 273
Endovascular treatment 262, 272
End-tidal nitrogen 103, 105
Enhanced recovery after surgery 232 244
Enteral nutrition 115, 117b, 119
benefits of 117b
dosing of 119
Entonox 76
Enzymes, release of 101
Ephedrine 49
Epidural analgesia 47, 80, 193
block neuronal impulses 193
Epidural anesthesia 48, 78
Epithelial growth factor 204
Errors in medicine 1
active 2
causation of 8
changing approach to 7
classification of 2
description 3
fixation error 3
incidence 2
lapse 3
latent 4
mode 3
sequence 3
slips 3
Erythropoietin, release of 314
Ethanol 160
Ethylene oxide sterilization 345
Etomidate 158, 228
European Society for Clinical Nutrition and Metabolism 116
Exenatide 231
Experimental therapies 109
Expiratory positive airway pressure 321
Extracorporeal membrane oxygenation 117, 221
Facet joint 208
absorption of 120
globules of 102
Fatigue 310
Fatty acid, essential 128
Fatty tissue 28
Fentanyl 76, 160, 168, 267
growth restriction 36
heart monitoring 50
macrosomia 72
surveillance 43
Fetus, delivery of 42
Fever, low-grade 317
Fiber 123
Fiberoptic bronchoscope guided 301
Fiberoptic bronchoscopy 302
Fire and accidents 147, 153
Fisher Scale Based on Computed Tomography Appearance for Subarachnoid Hemorrhage 260t
Fixation errors, types of 3
and electrolyte imbalance 261
management, role of 185
therapy 45
Food and Drug Administration 63, 151, 365
Forced expiratory volume 74
Forced-air blankets 198
Frail body 26
Frail organ system 26
Frailty 22
demographic and social factors 26
functional factors 25
implications of 26
index 24
pathophysiology of 25
physiological factors 25, 26
risk factors for 25
Functional neurological deficits 246
Functional residual capacity 282
G6PD deficiency 364, 372
Gabapentins 250
Gamma-aminobutyric acid 157, 158, 391
levels of 86
Gantacurium 62
Gas embolism 99, 100
clinical presentation 103
detection 104
differential diagnosis 106
epidemiology 99
etiology 100
management 107
pathophysiology 101
prevention 106
Gas flow controls 346
aspirate 117
banding 57
emptying 78
residual volume 126
continuous monitoring of 120
Gastrointestinal endoscopy 100
Gastrointestinal system 75
Gastrostomy, percutaneous endoscopic 119
General and regional anesthetic techniques 293
General anesthesia 47, 71, 78, 163, 190, 193, 227, 267, 285
amount of 357
considerations 49
and collagen disorders 257
and epigenetic variation 316
inheritance 37
Genicular nerve blocks 205
Geriatric nursing assessment and intervention 94
Gestations, multiple 69
Glasgow coma scale 260
score 259
Glenohumeral joint 356
capsule, quadrants of 355f
Glibenclamide 231
Glimepiride 231
Glipizide 231
Global Anesthesiology Server Network 136
Global positioning systems 133
Gloves, microperforation of 332
Glucagon-like peptide 1 232
agonists 231
insulin-potassium 235
monitoring 125
Glutamate 391
Glutamine 123
Glycemic control 240
Glycemic goals in perioperative period 229
Glycemic management in
intraoperative period 234
postoperative period 236
Glycosylated fibronectin serum levels 38
Gordon-green double-lumen tube 296, 296f
Guanylate cyclase activity 365
Gut ischemia 117
Hammer blow 258
Hand hygiene 347
nonperformance of 333
Hand sanitizers 140
Hazards 152
Headache 41, 258, 309, 310
Hearing 92
disability 155
impairment 94
disease, ischemic 75
failure 247
acute decompensated 318
congestive 44, 75
incidence of 27
Heat shock protein 316
Heating gel pad 198
Heating ventilation and air conditioning system 328, 329
Hemodialysis 125
Hemoglobin 43
concentration 314
molecule 364
normal 364
Hemolysis, elevated liver enzymes, and low platelets syndrome 34, 36, 42, 51
hepatic 36
postpartum 73
pulmonary 182
subarachnoid 257t
Hepatic dysfunction 36, 122
Hepatic failure 125
B viruses 149
C viruses 149
Hiatal hernia 75
High pulmonary
capillary permeability 314
vascular resistance 311
High-altitude pulmonary edema 308, 311, 314, 317, 319
clinical presentation 317
differential diagnosis 319
investigations 318
pathophysiology 314
prevention 323
treatment 320
High-flow nasal cannula, role of 185
High-flow nasal oxygen 277279, 289
components of 280f
equipment for 278
in critical care, indications of 281
Hindsight bias 8
Hip fracture 379
Histamine 62, 368
Hormone angiotensin 70
Human error, causes of 6
Human immunodeficiency virus 136, 149
Humeral head 356
Hunt and Hess classification 259t
Hyaluronic acid, intra-articular 205
Hydralazine 44
Hydrocephalus 260
Hydrogen sulfide 370
toxicity 370
Hyperactivity disorder 162
Hyperbaric chambers 320
Hyperbaric oxygen therapy 109
Hyperdynamic circulation 40
Hyperglycemia 226, 240
management of 226
perioperative 226
Hypernatremia 261
Hyperreflexia 41, 372
Hypersensitivity 59, 60
Hypertension 35, 71, 391
acute management of 44
chronic 35, 43
gestational 35
high-altitude pulmonary 308
in pregnancy 35
postpartum 37
pregnancy-induced 34, 35, 39, 51, 72
primary pulmonary 316
refractory 50
Hyperthermia 372
Hyperuricemia 41
Hypocaloric feeding 115
Hypoglycemia 236, 391
Hypoglycemic episodes 226
Hypokalemia 183
Hypomagnesemia 183
Hyponatremia 391
exercise-associated 319
Hypophosphatemia 123, 183
Hypotension 218, 386
deliberate 384, 387
intraoperative 385
Hypothalamic ischemia 261
Hypothermia 193
inadvertent perioperative 190, 194
intraoperative 196
Hypothesis 22
system integration failure 86
Hypoxemia 58, 283, 364
arterial 317
worsening 117
Hypoxia 218
alveolar 314
inducible factor 314, 316
perinatal 161
prevention of 284
treatment in 277
Hypoxic pulmonary vasoconstriction 308
Hysteroscopy 110
Iatrogenic pressure 100
Ifosfamide 370
toxicity 369
Immobilization 94
Immune modulators 123
Immunoglobulin E 149
Inclusion 94
Indian armed forces acclimatization schedule 312t
Induction 263
Infections 149
control measure 329
healthcare-associated 332
Inflammation, chronic 73
Inflammatory cell 70
Inflow ducts 329
Infraspinous fossa 356
Inhalational agent 29, 76, 228
Injury 173
Inspired oxygen, fraction of 176, 181, 279
infusion 235t
intermediate-acting 233
regimen 233
subcutaneous 234
Integrated multiple variables index 176
Intensive care 363
unit 92, 115, 127, 145, 173, 194, 230, 248, 278, 283, 377, 379
Interleukin 70, 217
Internal carotid artery, intercavernous 259
International Commission on Radiological Protection 148
International Subarachnoid Aneurysm Trial 262
Interscalene block 353
Interventional neuroradiology, evolvement of 256
Intervertebral disk degeneration 203
Intestinal contents, aspiration of 117
Intra-abdominal pressure 77, 126
Intra-aortic balloon pump 221
Intra-arterial stenting 261
Intra-arterial vasodilator therapy 261
Intracranial aneurysm 256, 258, 259t
management of 274
specific features of 259t
Intracranial pressure 261, 262, 273
Intradiskal injection 207, 208
Intraoperative blood pressure 387
fluctuations, effect of 385
management 385
Intrapulmonary shunting 101
devices 61
growth restriction 42
Intravenous administration sets 107
Intrinsic positive end-expiratory pressure 279
Invasive blood pressure monitoring 50
Invasive central hemodynamic monitoring 50
Ionizing radiation 267
Ipsilateral phrenic nerve 353
Iron, oxidation of 364
causes of 219
reperfusion injury 369
Ischemic angina pain 215
Ischemic evaluation, perioperative 220
Isocaloric feeding 115
Isoflurane 158, 160
Isophosphoramide mustard 370
Isoquinolinium muscle 62
James reason's Swiss cheese model of causation of errors 5
Jet ventilation, high-frequency 304
Joint Association of Obstetric Anesthesiologists 288
Joint British Diabetes Societies 230
Inpatient Care Group 239
Ketamine 158, 160, 228
Ketoacidosis, diabetic 226, 239
Ketonemia 239
disease, chronic 246
injury, acute 122, 385
Knee arthroplasty, unicompartmental 245
Labetalol 44, 267
Labor analgesia 46, 76
Lake Louise acute mountain sickness score 310t
Lake Louise criteria for
classification of high altitude 309t
clinical diagnosis of high-altitude pulmonary edema 309t
Laminar airflow 332t
plenum 329
Laminectomy 100
Laparoscopy 111
Laryngoscope's light bulb, failure of 134
Latex allergy 149
Latissimus dorsi 355
Left ventricle impairs ventricular filling 102
Left ventricular
dysfunction 40
failure 40
Leukocytes 203
Leukomethylene blue 363
Leukotrienes 368
Ligamental injuries, multitudes of 203
Light weight portable hyperbaric chambers 320
Light-headedness 310
Lignocaine 267
Linagliptin 231, 232
Lipids 121
Lipophilic cavity 55
Liraglutide 231
Liver 373
function 125
tests 126
Local anesthetic toxicity, occurrence of 353
Long chain triglyceride 128
Low back pain, chronic 206, 209
Low bispectral index 29
Low minimum alveolar concentration 29
Low molecular weight heparins 80, 250
Lung 182
conditions, chronic 182
diseases 378
injury, acute 373
water, excessive 182
Magnesium sulfate 45, 50, 51
Major adverse cardiac event 220, 378
Major cardiovascular surgery 366
MallinckrodtTM double-lumen tubes 297, 298f
patients at risk of 116
universal screening tool 116
Malpractice claims 147, 152
Maternal stabilization 51
Maxillofacial trauma 281
Maximum allowable concentration 330
Maximum inspiratory pressure 175
Mayo Anesthesia Safety in Kids Study 163, 165
Mayo Clinic-Olmstead County Studies 162
Mean arterial pressure 262
Mechanical ventilation 173, 178fc, 181fc, 383
stages of 174
dispensation of 16
errors, analysis of 13
Medium chain triglyceride 128
Melatonin 160
disturbance 259
failure of 12
hazards 147, 150
health 378
status 372
Meperidine 76
Metabolic abnormalities 117, 183
Metabolic disturbance, core of 70
Metformin 231
Methemoglobin 364, 366
formation of 364
levels of 364
Methemoglobinemia 364
treatment of 363, 365
Methylene blue 363, 364, 366, 367, 370, 372, 373
adverse effects 371
contraindications 372
current status of 363
historical background 363
mechanism of action 364
on anesthetics, effect of 365
physiochemical properties 363
Michigan Health System 15
Micronutrients 123, 126
deficiency of 122
Midazolam 151, 160
Miglitol 231
Military antishock trousers, use of 107
Milrinone 261
Minerals 30
Mini nutritional assessment 116
Minimum alveolar concentration 160, 267
Mitochondria, number of 314
Mobile 138
devices 135
health imaging 135
information technology applications in hospital scenario 134
phone 134
Modern double-lumen tubes 297
Monge disease 308
Monitoring nutritional therapy 126b
Mood 24
Morphine 168, 389
Mucociliary clearance function 279
Multicenter randomized controlled trial 282
abdominal 24
mass 24
exaggerated loss of 28
relaxants 228
weakness 58, 173
Musculoskeletal system 28
Musculoskeletal tissues 209
Myasthenia gravis 58
Mycobacterium tuberculosis 136
Mydriasis 372
Myocardial infarction 29, 215, 216, 226, 378
Myocardial injury 216, 385, 386
after noncardiac surgery 216
Myocardial oxygen 215, 366
Myocardial potassium adenosine triphosphate 231
Myoclonus 372
Myoglobin 314
Myosin, dephosphorylation of 367
Myotonic dystrophy 58
Naruke tubeTM (Koken medicals) 300
Nasal bleeding, profuse 281
Nasal obstruction, severe 281
Nasal prongs 280
Nasopharynx 340
National Accreditation Board for Hospitals and Healthcare Providers 330, 331t
National Audit Project 277
National Council of Radiation Protection and Measurement 148
National Glycohemoglobin Standardization Program 227
National Institute for Health and Clinical Evidence Guidelines 196
National Institute for Health Care Excellence 206
National Surgical Quality Improvement Program 219, 244
Nausea 76, 391
Neostigmine 55, 382
Nephropathy, contrast-induced 273
Nervous system 27
Neural development, timeline of 158f
Neurological disturbances 36
Neuromuscular abnormalities 182
Neuromuscular blockade 58, 60
Neuromuscular blocking
agent 55, 56, 63
drugs, new reversal agents for 63t
Neuromuscular monitoring 382, 383
technique 382
Neuroradiological procedures 273t
Neurotoxic substance 370
Neurovascular abnormalities, types of 256
Neurovascular lesions 274
Nicotinamide adenine 364
dinucleotide 370
phosphate 363
Nicotine 390
Nifedipine 44, 322324
Nimodipine 261
Nitric oxide 322, 364
synthase 364
Nitrogen 99
Nitroglycerine 44
Nitrous oxide 76, 158, 160
N-methyl-D-aspartate 157, 158, 160, 391
Noise effects 155
Noncardiac surgery 215, 386
Noncatecholamine 363
Nonintradiskal platelet-rich plasma injections 208
Non-invasive ventilation 184, 280
use of 184
Non-protein energy 128
Nonsteroidal anti-inflammatory drugs 205, 249, 392
Normoglycemia 230
North American Spine Society 208
Nosocomial infections, spread of 137
Numerical rating scale 207
Numerous venous channels, presence of 111
Nursing delirium screening scale 90
NUTRIC score 127
Nutrients, delivery of 126
Nutrition 24
in intensive care unit 115
monitoring 125
requirements 115
risk screening 116
therapy 115
Nutritional status, assessment of 116
parturient 70, 72, 79
issues and management of 68
Obesity 68, 69, 73, 74t, 79, 80, 246
in pregnancy 73fc
pathophysiology of 70
morbid 57
Obstetric management 42
antihypertensive therapy 43
route of delivery 43
timing of delivery 42
Obstructive coronary artery disease 216
Obstructive sleep apnea 71, 72t, 74
incidence of 88
Occupational health hazards 154
Omega 3 fatty acids 122
Operating room 153, 328, 332, 345, 347
biomedical waste management 345
cleaning 345
complex design 329
disinfection 345
Operation theater 145, 149
Operative delivery 47
Ophthalmic manifestations 41
Opioids 15, 93, 158, 228
anesthetic techniques 228
intravenous 47
parenteral 76
Optimal pain management 390
Oral glucose tolerance test 227
Oral hypoglycemic agent 231, 231t
Oral nifedipine 44
Orthotopic liver transplantation 369
Osmolarity 119
Osteoarthritis knee 203, 205, 206
Outpatient arthroplasty risk assessment 247
Oxidation 314
Oxygen 76, 321
arterial pressure of 309
delivery 289
flow 280
affinity 314
dissociation curve 314
partial pressure of 74, 104
standard 282
supplemental 322
Oxygenation 176, 277
adequate 175
clinics 145
intensity 208
reassessment of 390
Pancreatitis, acute 125
Papworth bivent tube 303
Paracetamol 250
Paradoxical air embolism 100
Parenteral nutrition 115, 121
complications of 122b
components of 121
Parkinson's disease 87
Particulate air, high-efficiency 332, 347
Patent foramen ovale 101, 316
Peak plasma concentrations 28
Pectoral nerve, lateral 354356
Pediatric Anesthesia 157, 288
and Neurodevelopment Assessment Study 163, 164
Percutaneous coronary intervention 215
Perfusion 101
Perioperative glycemic control 230
Perioperative myocardial injury, pathophysiology of 217fc
Perioperative Quality Initiative 385
Consensus-building Conference 385
Peripheral capillary oxygen saturation 50
Peripheral vascular disease 87
Peritoneal desufflation 108
Pethidine 76
Pharmacological prophylaxis 323
Pharyngeal dead space, washout of 279
Phenotype method 23
Phenylephrine 261
levels 126
supplements 123
Phosphodiesterase-5 inhibitors 322
Physical hazards 146, 147
Pioglitazones 231
Placenta, delivery of 42
Plasma 60
Platelet derived growth factor 204
Platelet-rich plasma 203205, 209, 210
administration of 203
evidence of 205, 206
studies of 207
current use of 209
proposed mechanism of 204
role of 206
studies, limitations for 205
types of 204
Pleural effusion 182
Pneumonia 58, 182, 282
ventilator-associated 120, 173
Polysomnography 72
Polyurethane 297
Polyvinyl alcohol 272
Poor pregnancy outcomes 147, 150
Poor ventilatory response 314
PortexTM (Smith medicals) right-sided double-lumen tubes 299, 299f
Positive end-expiratory pressure 107, 175, 181, 383
Positive pressure ventilation 80, 100
Positron emission tomography 148
Postanesthesia care unit delirium 86
Postembolization angiography 272f
Posterior cord 355, 356
Postextubation stridor, treatment of 185
Postinduction hemodynamics 365
Postoperative cardiac
complications 215
computed tomography angiography 217
Postoperative cognitive dysfunction 28
chances of 95
Postoperative delirium 85
cognitive outcome of 95
development of 87, 87t
pathophysiology of 86
prediction of 91
prevention of 93
treatment of 93
workup for 89fc
Postoperative myocardial injury 215, 216
causes and management 215
Postoperative pulmonary complications 380, 381
Preanesthetic evaluation 46
Preanesthetic preparation 267
Precordial Doppler ultrasound 105
Predicted left main stem bronchus 301
diameter 301
Pre-eclampsia 3436, 39, 72
anesthetic management of 46
de novo 35
late onset 38
long-term implications of 42
management of 34
oncidence of 37
pathogenesis of 37
prophylaxis of 38
risk factors for 39, 39t
signs of 35
symptoms of 35
Pre-existing respiratory infection 316
Pregnancy 69
and obesity 73
normal 74t
thromboembolism in 73
Pre-high efficiency particulate air filters 329
Prematurity 161
Preoperative evaluation and anesthetic plan 262
adequate 74
and apneic oxygenation during intubation 284
Pressure support ventilation 177
Prevertebral fascia 360
Progesterone 312
Proinflammatory mediators 70
Prolonged weaning failure, management of 183
Prophylactic aspirin therapy 38
Propofol 158, 160, 193, 228, 265, 267
Proportional assist ventilation 179
Prostacyclin 37
Prostatectomy 100
Proteinuria 35
Pseudomonas aeruginosa 332
Psychoactive medicines 94
Psychosis 91
Pulmonary air 100
Pulmonary arterial pressure 313
Pulmonary artery catheter 105
Pulmonary catheters 50
Pulmonary edema 36
risk of 45
Pulmonary embolism 101
Pulmonary failure 124
Pulmonary function, adequate 175
Pulmonary hypertension 75, 323, 373
development of 314
Pulmonary vasodilator, production of 314
Pulse oximetry 106, 317
Pyramidal rigidity 372
Pyridostigmine 55
QT prolongation 260
Radial arterial cannulation 49
Radiant heating 198
Radiation exposure 146, 148
Radio intervention 271
Randomized controlled trial 178, 209
Rapid ascent profiles 315
Rapid sequence induction/intubation 286
Rapid shallow breathing index 177
Reactive airway disease 319
Recent nasal trauma or surgery 281
Receptor agonists 391
Receptor antagonists 391
Red blood cell 92, 102, 364
Refeeding syndrome 122, 122b
Reflective blanket 199
Reflective clothing 199
Regional anesthesia 47, 164, 190, 248
considerations 48
Remifentanil 168
toxicity of 167
Renal dysfunction 36, 60
Renal failure 36, 124
Renal function 9
Renal replacement therapy, continuous 125
Renin-angiotensin-aldosterone 316
Reported Edmonton Frail Scale 24
Respiration 182
Respiratory depression 76, 79
Respiratory distress 287
clinical signs of 281
Respiratory failure 58, 283
Respiratory intermediate intensive care units 184
Respiratory manifestations 40
Respiratory muscle
reserve 176
strength 176
Respiratory pathology, absence of 182
Respiratory rate 175
Respiratory symptoms 36
Respiratory system 27, 73, 79, 261
algorithms 134
cardiopulmonary 109, 134
rooms 145
Reversal agent sugammadex 228
Revised cardiac risk index 219, 221
Richmond agitation-sedation scale 89, 90f
Robertshaw design 297
Robertshaw double-lumen tube, left-sided 297f
Robertshaw tube 296, 305
Robot-assisted medication preparation 16
Robotic preparation 16
Rocuronium 13
induced neuromuscular blockade 58
potency of 57
Roland-Morris disability questionnaire 208
Rosiglitazones 231
Rotator cuff repair 357
Royal College of Anaesthetists 277
RüschTM left-sided double-lumen tubes 298, 298f, 300
Sacroiliac joint 208
injection 208
Safety critical patient areas 139, 140
Salmeterol 324
Sarcopenia 24, 28
Scapula, spine of 356
Schizophrenia, psychotic illnesses like 91
Sedation 357
risk of 76
lowering of 391
prophylaxis 45
Selective serotonin reuptake inhibitor therapy 372
Sensory motor block 77
Sepsis 122, 124, 368
Sequential organ failure assessment 127
Serotonin 157
receptor agonists 391
toxicity 372
signs of 372
symptoms of 372
Serum creatinine levels 36
Severe pre-eclampsia 36t, 4042, 46, 48, 49
systemic manifestations of 40
Sevoflurane 158, 167
subclinical 160
SheridanTM (teleflex) 299
Shock 364
anaphylactic 368
hypovolemic 369
septic 368
vasodilatory 366, 368
vasoplegic 366
worsening 117
Short nutritional assessment questionnaire 116
dystocia 72, 73
innervation 354f
painful procedures 353
regional anesthesia 353
surgery, regional blocks for 353
SilbronchoTM 299
Simple ventilatory parameters 176
Simplified weaning index 176
Simulation techniques 134
Single shot spinal anesthesia 48
Sinusitis 173
Sitagliptin 231, 232
Sleep deprivation 94
Smart magnetic resonance imaging 134
SmartCareTM 180
and medical equipment 139
application 135
cost-effective ventilator 136
guidelines regarding safe use of 140
in anesthesia 133
Sniff position 79
Social networking sites, variety of 135
Society for Ambulatory Anesthesia 230, 234
Society for Healthcare Epidemiology of America 333
summary of 334t
Society of Critical Care Medicine 116
Society of Thoracic Surgeons 237
channel blockers 391
nitroprusside 44
Soldiers deployed for counter-insurgency operations 311
Soluble endoglin 38
Soluble guanylyl cyclase 364
inhibition of 364
Somnolence 79
Sparing phrenic nerve 353
Spetzler-Martin Grade of Arteriovenous Malformation 270t
Spetzler-Martin grading system 269
Spinal anesthesia 48, 77, 163
block neuronal impulses 193
study 163
Spinal fusion 100
Spinoglenoid notch 356
Spontaneous breathing
pattern of 176
trial 173, 177, 178fc, 181
Spontaneous intermittent mandatory ventilation 177
Spontaneous ventilation 287
Sputum smears 136
Stable metabolic status 175
Steam sterilization 345
Stenotrophomonas maltophilia 332
Sterile cockpit rules 138
measures 341
techniques of OR 341
Steroidal nondepolarizing neuromuscular agents 55
Steroids, intra-articular injection of 205
Stethoscopes 106
Strain limited human attention span 141
ambience-related 147, 151
and burnout 147, 150
operative 382
Stroke 25
acute 273
history of 87
volume variation 219
Stromal vascular fraction 208
Subarachnoid hemorrhage 256, 273
diffuse deposits of 260
severity of 259
systemic manifestations of 260
Subomohyoid 358
Subscapular fossa 356
Substance abuse 147, 151, 257, 390
Sugammadex 55, 58, 60, 61, 63, 382
administration of 59
dose 56, 56t
reversal 63
rocuronium complex 60
use of 56
Sulfonylureas 231
Superficial cervical block 357
Superior labrum
anterior 357
posterior 357
Supraclavicular area 360
Supraclavicular nerves 357, 360
Suprascapular fossa 358
Suprascapular nerve 354356
block 358
Suprascapular notch 354, 356
Supraspinous fossa 356
Surgical clipping, anesthetic management of 262
Surgical site infection 195, 328
causes of 328
Swan-Ganz catheter 219
Synaptogenesis 165
Syndrome of inappropriate secretion of antidiuretic hormone 261
Systemic inflammatory response 102
Systemic lupus erythematosus 39
Systemic vascular resistance 40, 366
Tachycardia 221, 317, 372, 386
Tachypnea 317, 372
Testosterone 30
The 1800 rule 233
Thermal dysregulation, causes of 192
Thermal insulation mechanisms 199
Thermoluminescent dosimeter 267
Thermoregulation 190, 191
intraoperative 190
Thiazolidinediones 231
Thiopentone 228, 265
Third nerve palsy 259
Thrombocytopenia 36, 41
Thromboelastography 49
Thromboembolism 73
Thrombus 215
Tidal volume 175
Tissue 314
cytochrome oxidase 314
Total hip arthroplasty 244
Total intravenous anesthesia 134
advantage of 88
Total joint arthroplasty 244, 245, 252
program 245
Total knee
arthroplasty 244
replacement 205
Total parenteral nutrition 237
Tracheostomy 183
Traditional nerve blocks 353
Tramadol 391
advantage of 391
diclofenac, fixed-dose combination of 392
pharmacodynamic activity of 392
Tranexamic acid 249
Transcranial Doppler ultrasound 106
Transesophageal echocardiography 51, 105, 219, 316
Transforming growth factor-beta 204
Transnasal humidified rapid-insufflation ventilatory exchange 285
Transthoracic echocardiography 377
Transverse abdominis plane block 80
Transverse humeral ligament 355
Trauma 124, 145
Tremor 371, 372
Tricyclic antidepressants 87
Triglycerides 126
Trophoblastic invasion, failure of 37
Tumor necrosis factor 217, 227
alpha 116
Ultrasonography 303
limitations of 319
lung comets, presence of 319
Univent tube 294f
Upper airway 173
Upper extremity 359
distal part of 357
Upper gastrointestinal bleeding, refractory 117
Urea 126
Urine dipstick 35
Uteroplacental blood flow 41
Vaginal rings 61
Variable rate insulin infusion 232
Vascular air embolism 99, 112
Vascular catheters 107
Vascular endothelial growth factor 204
Vasoplegia 366, 367
Vasoplegic syndrome 366, 367
Vasopressor 49, 364
Vasospasm, management of 261b
Venous air embolism 103
Venous thromboembolism 81, 250
Ventilation 312
Ventricular pressures 218
Ventricular septal defects 316
Venturi mask 277
Video laryngoscope 134
Visual aid 92
Visual analog scale 207, 389
Visual disturbances 36
Visual impairment 94
Vital capacity 175
Vitamin 30, 121
C 40
D deficiency 38
D supplementation 123
Viva-sight double-lumen tubes 304f
Volatile anesthetic gases 147
Vomiting 76, 371
Wander app 134
Warming, methods of 198
Waste gas exposure 146, 147, 154
Water distribution system 332
Weakness 310
Weaning 184
anticipation of 174
conventional methods of 177
different conventional modes of 178
failure 180
fluid management of 185
combination of 175
common 176t
protocol 180
readiness, assessment of 175
ventilator modes for 178
White blood cell 195
White coat hypertension 35
World Federation of Neurological Surgeons Grading for Intracranial Aneurysm 259t
World Federation of Neurosurgeons Scale 259
World Health Organization 22, 69, 136, 146
Wound infection 73
Chapter Notes

Save Clear

Errors in Medicine: A Perioperative PerspectiveCHAPTER 1

Sanjay Sharma
There is increasing emphasis on minimizing medical errors, which have been described as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”.1 Realistically, this would include both the implementation of an inappropriate plan, or a good plan not executed as intended. These errors are usually unintentional and not malicious or deliberate.
The errors of omission or commission, in both planning and execution of various processes, are included irrespective of whether the adverse outcome actually occurred or was likely. It thus provides a useful template for research into faulty processes that contribute to majority of errors that could fly under the radar, as they do not actually cause harm. Equally, it takes focus away from trivial “slip ups” that do not have the potential to actually result in an adverse outcome.
The healthcare industry is inspired by, and follows the model of the airline industry by investigating every near miss and error. This initiative, to analyze each event irrespective of whether it actually eventuates in a bad outcome, would improve reliability and safety. The healthcare industry aspires to achieving this level of investigation in the absence of a culture of blame.
As opposed to unplanned errors, the term violation applies to planned and deliberate deviation from accepted protocols and standard operating procedure.2 Violations may sometimes involve extenuating circumstances with pressures of time or staffing, and also include deliberate flouting of rules in some instances. Omission of an appropriate preoperative assessment, waiving the “time out” process, and omitting to check the anesthetic machine prior to commencement of procedure all constitute violations.
Moyen et al.3 clearly defined these errors, but then also further defined medication errors, especially those that were preventable. Other definitions, with errors subdivided into slips and lapses have also been alluded to, and these will be discussed further in the chapter.2
There is increasing recognition and attention to medical errors irrespective of the actual severity of outcome. “The real problem is not how to stop bad doctors from harming, even killing, their patients. It is how to prevent good doctors from doing so”.4 The Institute of Medicine report,5 aptly titled “To Err is Human”, estimated that between 44,000 and 98,000 hospitalized patients die annually in the USA as a result of medical errors. Australian Healthcare Quality study,6 found that adverse events (unintended injury or complication caused by healthcare) occurred in 16.6% of hospital admissions, with 51% of these events judged to be “highly preventable”. UK report7 found that medical errors caused harm (death and injury) to in excess of 850,000 patients admitted to National Health Service Hospitals annually. Other reports, published worldwide, show widespread acceptance of the impact of medical errors on patients admitted to hospitals.811
Errors can broadly be classified into active errors as those occurring around an incident, and latent or systemic errors that may not be immediately evident or visible.12
Active errors are usually attributable to personnel directly caring for patients, such as nursing and medical staff. An example of an active error is inadvertent administration of a wrong medication, operation performed on wrong site, or even wrong patient. These errors may sometimes be one-off, due to carelessness or negligence, but sometimes a reflection of latent errors—an accident waiting to happen.
Latent errors are often systemic, resulting from poor planning or execution. In the scenario of a wrong medication being administered, the latent error potentially is that of two distinctly different medications packaged in similar looking ampoules, and placed close together on the trolley—an absolute recipe for disaster. This error would not be identifiable until an active error was made and attributed to this problem on one or more occasions.
Active Errors
Active errors, directly attributable to personnel, have further been classified into simple omissions such as slips and lapses, and a third category of fixation errors.12,13 Slips and lapses are exactly occurring frequently when one is preoccupied or distracted and hence cannot focus appropriately on the job they are meant to do.12 Slips and lapses can involve errors attributable to subconscious and conscious cognition.133
Explanation of the etymology of slip suggests an unintended action or word, such as slip of the tongue or slip up. Rotating the wrong knob on an anesthetic machine, thus delivering nitrous oxide instead of air, is a classic example of anesthetic slip. Though slips seem fairly innocuous, they can sometimes result in adverse outcomes. Clarity on slips in anesthesia was provided by Norman14 who categorized slips into sequence errors, description errors, and mode errors.
  • Sequence errors: Elements of a task are all performed, but in an incorrect order or sequence. A typical example would be injection of muscle relaxant before actually giving induction agent.
  • Description errors: Correct action performed, but on the wrong agent or object. This is exemplified by an appropriate action such as turning off the knob, but wrongly the knob of nitrous oxide rather than oxygen.
  • Mode errors: Performance of correct action but the setting of equipment is in the incorrect or wrong mode. Once the circuit switch is set to ventilator mode, attempts to squeeze a breathing bag to ventilate the patient highlights a mode error.
When an intended action is missed, often due to distraction or time pressure, it qualifies as a lapse. Leaving one's car unlocked and rushing into a shopping center is a typical example of a lapse. In clinical work, a lapse occurs when a medication is not given though it was intended to.
Fixation Error
This is a third variety of active error, seen more commonly in a crisis or stressful situation. Allnutt14 describes extreme concentration on one action at the cost of other more useful actions as “coning of attention”. He describes this tendency to focus on a particular task or source of information without “taking a step back” to review others options. Some emergency situations call for a change in plan or diagnosis but the persistent failure to recognize this and stick to the original unsuccessful action is a classic example of fixation error.15 An example would be the ongoing attempt to “fight” with a piece of jammed essential lifesaving equipment rather than picking an alternative which may be easily available.
Few common types of fixation errors are:
  • “This and only this”: In this scenario, the caregiver is fixated on a diagnosis and will not consider alternative plans despite investigations suggesting otherwise.4
  • “Everything but this”: Another variety where the caregiver does not acknowledge a major problem and hence this is left unattended, while minor issues are attended to.
  • “Everything's okay”: Similar to the above, where evidence is ignored to the detriment of the condition.
A classic example of fixation error was evidenced in a 1972 plane crash, where the crew gave all their attention to a defective indicator light. So fixated were they on this light that they ignored a major looming disaster with autopilot disengaging until the plane actually crashed.
Simulation exercises for anesthetic emergencies often display fixation errors, irrespective of the seniority and experience of the anesthesiologist.16,17 A positive approach to this error and reflection on methods to avoid this in real life serves a purpose of simulation exercise.
Latent Errors
Why do errors occur repeatedly? Bogner's theory of error scripts—“all the men and women are merely players”.18 He suggests that the script may incorporate faults, which induce or provoke errors, and this sets the stage for adverse outcomes. The individuals held responsible are actually merely “actors” and should not be the focus of punitive action, since they are mostly “following a script”.
Anesthesia is unique in that one practitioner singlehandedly decides the medication to be administered, prepares, and administers it and then monitors the patient to ensure that no complication ensues. This is complex at the best of times, and provides a template for mishaps and errors especially in times of stress or crisis.
Recently, there have been news items relating to adverse outcome when tranexamic acid was injected intrathecally as the ampoule was similar to bupivacaine, and easily mistaken. Both had orange-colored lettering, and were placed side-by-side on a trolley. Another such potential disaster related to similarity between ondansetron and vasopressin causing accidental injection of the wrong agent. Errors relating to accidental intrathecal injection of chemotherapeutic agents meant for intravenous administration have been reported on many occasions both in UK and Australia.19 Despite extensive publicity, litigation and large payouts, beside a manslaughter conviction, these errors have recurred. It emphasizes the lesson from Bogner's theory that the script is error-prone. Two medications, one intended for intravenous administration and the other for intrathecal injection, are packaged similarly, in similar volumes, and presented to the doctor (“actor”) for administration. The error recurs despite changing doctors, because the script is unchanged.
Whilst medical errors resulting in adverse outcomes are often the subject of scrutiny, root cause analysis, and litigation, it is moot to remember that adverse outcomes actually follow only in a small proportion.5
zoom view
Fig. 1: James Reason's “Swiss cheese” model of causation of errors.21 Typically, defense is formed by multiple layers, and when the holes align in the form of medical errors, a poor outcome ensues.
The larger proportion of errors or “near misses” may not be associated with adverse outcomes either due to good fortune, or to being noted and dealt with in a timely manner.5,20
The Swiss cheese model of error causation proposed by James Reason has been extrapolated to healthcare.21 The principle of Swiss cheese theory suggests that several layers of defense are in place in most hospitals to protect against adverse outcomes relating to medical errors. These layers are represented by several slices of Swiss cheese, each with holes in them. These holes are representative of flaws in the system, predisposing to error. When a situation arises in which the holes in different layers align, or flaws “match up”, injury and adverse outcomes are likely as illustrated in Figure 1.21
Near miss,1 incident, and accident23,24 are other terms that have been used in some safety critical industries. However, the term error carries a connotation of stigma, and is often associated with negative psychological impact on the clinician. An antagonistic term that strongly promotes the blame game, an error can also be used as the basis for a malpractice claim.2527 This fear adds to feelings of anger, inadequacy, guilt, anxiety, and depression.5,20,28 A negative approach such as this carries the potential to decrease efficiency of the “accused” clinician, sometimes even resulting in them giving up an otherwise good career in medicine.20 It has been suggested that the term error be restricted to processes for redesigning of systems and improvement of patient safety. Identifying error and providing feedback and education have been acknowledged as good resources to improve patient safety.5,20,29,30
6As per the Swiss cheese theory, multiple complex factors contribute to causation of errors.12,22 The human factor needs to be factored into the understanding of error occurrence, which is often lacking given intolerance by public and the law. Prevention of errors is more likely to be resolved by education, as well as addressing underlying systemic causes, and not by punitive action against clinicians. Ultimately errors can be reduced or mitigated once health systems are safer, not by apportioning blame and punishing individuals.5,20,22,31 Errors need to be recognized and acknowledged to then create educational opportunities and improvements in safety of healthcare.26
Human factors involve the complex interaction between humans and environment or technology.22 In medical field, the subset most frequently studied was anesthesia and intensive care, which have similarities to previously studied fields such as engineering, design, management, and ergonomics.32 Not only is the field of anesthesia most studied for human factors in accident causation, but is also identified as significantly invested in strategies for patient safety.33,34 With inspiration from aviation industry especially in relation to checklists, drills and simulation, this specialty has made rapid advances in use of technology for patient monitoring and implementation of safety guidelines. Analysis of human factor in causation of errors suggests 64–83% of anesthetic accidents can be linked to human error.13
The causes of human error in aviation mishaps were identified but not limited to long working hours causing fatigue with flawed cognition and decision making processes. Team issues relating to teamwork, leadership, and interpersonal communication all potentially contribute to human error.35 Following this analysis, attempts were made to decrease errors through crew resource management (CRM), which has become increasingly sophisticated and had increasing uptake and approval.36 Initial resistance was overcome with improved training and evidence of human factors in causation of accidents.
The specialty of anesthesia has followed the strategies implemented in the aviation industry toward safer practice. Besides technical skills and knowledge, anesthesiologists’ nontechnical skills (ANTS) including task management, teamwork, situation awareness, and decision-making are taught and assessed in the anesthesia training program.37
Another similarity of anesthesia to aviation industry is that both are highly complex, dynamic, and tightly coupled. Not only are complex interactions 7involved in ensuring a good outcome, but also the unpredictable characteristics and responses of the human undergoing anesthesia make this more difficult and need personalized planning.38,39
The term “tightly coupled” reflects the critical importance of time in the processes, which cannot wait or stand by.40 Induction of anesthesia is a tight time dependent process, where medication is administered followed by paralysis and intubation. These need to be performed in quick succession. The anesthesiologist cannot afford to be distracted, or undertake some other task leaving patient unattended, without dire consequences. These highly complex time coupled systems set the stage for increased likelihood of accidents.12 Perrow suggests that these accidents, very likely to occur in complex time coupled activities, should be viewed as inherent characteristics of such a system, so named “normal accidents”.40
The traditional approach to error has been to emphasize education and training, along with punitive measures and blame apportionment as a means of reducing errors and mitigating their effects.41 This was based on the premise that encouraging people to be more careful and motivated would improve safety by reducing errors. Whilst this seems obvious and straightforward, just focusing on individuals and pushing them to perform better has not really reduced accidents in industry analysis. The reason that person-focused approach has not worked is because accidents are often the result of interplay of systemic, organizational, and circumstantial factors rather than just one unsafe worker.32
Whilst encouraging and motivating people to do better, the culture of “naming, blaming, and shaming” the person deemed responsible deflects from the bigger picture to actually analyze the cause of error.42 The premise that blaming an individual for carelessness, negligence, and poor motivation will somehow eliminate errors, is flawed.
One of the major “side effects” of this blame culture is inculcating fear, so errors are covered up rather than admitted to. Multiple factors contribute to this inability to acknowledge an error. The training of medical students and doctors has been to aim for zero errors, by being extra careful and trying hard. It follows that doctors then see themselves and their practice as infallible, which is really a setup for trouble. When an adverse event occurs, which is inevitable in some situations, doctors see this as a professional and personal failure, and fear the shame that will follow when colleagues see them as incompetent. The feelings of guilt, shame, and isolation are often major enough for the doctor to become the “second victim”.43 It has been said that, “‥… medicine is often driven by the idea that perfection is possible and that mistakes are a personal and professional failure. This perfection mind-set … is laudable, admirable, and unworkable”.448
Recognition that errors are often based on complex interactions of human behavior with equipment and procedures forms the modern approach to understanding and addressing error. In contrast to the traditional approach, where human cognitive limitations have been targeted, the current approach is to accept these as the last link in events leading to adverse outcomes. It is accepted that fatigue and long hours of work, stress, preoccupation or distraction as well as forgetfulness can contribute to accidents, but this is certainly not the only major or leading cause of an adverse event.32 Acceptance of inevitability of errors in some situations and acceptance of human fallibility, besides designing and promoting safe systems is possibly the best way to improve safety.
Reason45 has listed some myths around error causation. These include:
  • Errors are made by bad people, casting a moral shadow of karma:42 Simply put, it suggests that people bring these bad events upon themselves, due to performing bad actions. This is clearly a myth, given that most errors occur to the best people performing the most difficult tasks or a good person having a bad day.
  • Errors are unpredictable and unpreventable: Another myth propagated around error causation relates to a perception of errors being random events, occurring without reason or warning. The reality is that errors do occur throughout a profession.
  • Highly trained individuals do not make errors: This is another myth, negated by the fact that errors are usual and common, though most are not associated with serious outcomes. Analysis from the aviation industry shows only about 100 major events a year on background of 100 million errors made by flight crew.46
  • Highly trained individuals make huge errors: It is commonly believed that highly-trained professional makes huge errors invariably causing bad outcomes. However, similar to the previous myth, statistics show errors may be common, but serious adverse events are rare due good preventative systems in place (e.g. alarms on anesthetic machine). Also, individuals who are highly competent are also well trained to detect and recover from errors before they actually cause a bad outcome.
Errors are not uniformly viewed, and like everything else, are subject to bias. They are largely classified into outcome bias and hindsight bias.
  • Outcome bias depends on adverse outcome. The worse the outcome, the more seriously an error is viewed.47 An interesting study where 112 anesthesiologists were asked their opinion about quality of care in 21 cases showed inverse relationship between worsening outcome and judgment of appropriate care.48 Put simply, the same set of circumstances 9(in this case standard of care) was judged more critically (as being worse) when informed that it was associated with bad outcome.
  • The benefit of hindsight or retrospective analysis, once the outcome is known, definitely alters analysis of errors and adverse outcomes. Psychologists have studied and confirmed the phenomenon of this bias, when those reviewing a sequence of events after the outcome can clearly see disaster looming. On the other hand, an experienced person actually involved in real-time management of the events may not be able to see events unfolding in a linear fashion.12
Staggering statistics from the United States show that nearly 10% of hospital inpatient costs are attributable to potentially preventable complications, of which medication error is a substantial contributor. Figures from 2006 estimated national healthcare costs at $940 billion, and the 9.4% contribution from errors equates to $88 billion.49
One of the major errors encountered in health industry is that of drug administration errors. These are estimated to account for 7,000 deaths in the United States, and a much larger number of people suffering, along with increase health costs.5052 Medication errors have been documented as the seventh most common cause of mortality in hospitalized patients, with worst culprits being antibiotics and anesthetic agents.53 Review and analysis of medication errors, and effective methods of prevention is one of the strategies pursued to reduce spiraling healthcare costs as well as adverse events.
Other studies have also substantiated the above figures relating to costs and morbidity from medication errors. Bates et al. have analyzed figures from a medium sized 700-bed hospital, and calculated 1 in 50 in patients have a preventable adverse outcome related to medications. This translates into increased hospital costs of $4,700 per admission or $2.8 million annually, which is considered preventable.54
One of the top reasons of medication error during inpatient stay is linked to polypharmacy, given that a third of inpatients are on five or more different medications.55 Newer medications may carry specific risks include drug interactions, and certain groups may be more susceptible to the adverse effects. The elderly population, with some age-related physiological changes including reduced ability to metabolize drugs, combined with needing a large number of medications, are at high risk of drug-related adverse outcomes. Research has shown increased incidence of adverse events in those over 65, possibly influenced by age-related decrease in renal function and polypharmacy.5610
The other high-risk population is young children, as drug prescriptions need to be tightly linked to body weight. Patients with limited ability to understand and follow instructions would also be at risk of adverse events. A recent study showed that two-thirds of emergency hospital admission occurred due to unintentional overdosage of certain medications. Of these, only four groups, specifically warfarin, insulins, oral hypoglycemics, and antiplatelet agents, accounted for 7 out of 10 emergency hospital admissions.57
Medications taken in error, if not prescribed can also result in significant adverse events. Specific groups of medications that have this potential include opioids, sedatives, antibiotics, potassium chloride and hypoglycemic agents, among others. Adverse events could potentially occur due to allergic response, even when medications are correctly administered. This is considered to be more commonly preventable in older population (90%) than in younger population (24%).58
A medication error index adopted by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) in 1996 was later revised in 2001. This index classifies errors based on impact to the patient, ranging from whether it actually affected the patient to the degree of harm resulting in temporary or permanent morbidity/mortality as depicted in Figure 2.
Medication errors in anesthesia are a significant contributor to morbidity as well as mortality. Extrapolation from statistics suggests that most anesthesiologists would be involved in at least one major error over an average career, with about 7 errors per year.51,53 Medication errors, in association with infusion pump problems, are reported to be the leading cause of deaths related to anesthesia in Denmark.59 Studies from other regions and continents have shown similar results. A prospective study of 10,000 anesthesia episodes from New Zealand showed 1 error for every 130 anesthetics administered.60 This along with some other studies listed in Table 1 highlights incidence of drug errors. In a Canadian survey less than 70% anesthesiologists reported adhering to practice of labeling syringes and reading labels before administration on a regular basis.61
Anesthesiologists are uniquely placed as the only subset in medical practice to prescribe, draw up, dilute, and administer drugs and then monitor patients for any complications. Given the high usage of medications for induction and maintenance of anesthesia, the urgency and sometimes crisis like situations, it is anticipated this will set the scene for errors associated sometimes with severe adverse outcomes.11
zoom view
Fig. 2: National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP, 2001).Source: 2014 National Coordinating Council for Medication Error Reporting and Prevention.80
Table 1   Incidence of medication errors in key studies.
Study period
Number of anesthetics delivered
Incidence of drug error
Percentage of drug error
Webster et al.60
Feb 1998– Oct 1999
Sakaguchi et al.65
Llewellyn et al.66
Jul 2005– Jan 2006
Cooper et al.70
Aug 2007– Feb 2008
Zhang et al.81
Mar 2011– Sep 2011
12An average anesthetic career would likely involve administration of 1 million anesthetics. A significant proportion of these would be elderly patients, presenting for high-risk surgery, sometimes in urgent and emergency situations. Drug interactions with medications the patients may currently be using, and failure to recognize or reconcile these can lead to disastrous situations. Emergency surgery and anesthesia can sometimes be dynamic and rapidly changing or deteriorating, which demands urgent medication possibly without rechecks.
Other potential confounders are the factors that influence the patient's ability to tolerate any errors, including reduced physiologic reserve due to emergency condition or trauma needing surgery, besides of course extremes of age, and other conditions such as pregnancy.
The numbers for intensive care units appear to be a little higher with 133 medication errors reported per 1,000 patient days.62 It has been acknowledged that a widespread pattern of under-reporting in most healthcare systems means that the actual rate of medication errors would actually be much higher.63 Also, given that the actual outcome of an error is influenced by so many factors, studies need to focus and reflect on errors or near misses, irrespective of actual outcome of harm.
As discussed, medication errors are often attributable to failure of pathways, processes, and systems, rather than individual negligence. Lack of protocols for administration of medications, and shortage of staff to assists with checks and other processes are typical systemic latent causes of medication errors. Staff shortage can also result in some practitioners needing to work beyond reasonable hours leading to fatigue or distractions/interruptions from attempting to manage multiple cases. Australia and New Zealand College of Anaesthesia (ANZCA) has published statements on fatigue and distractions, and need for safe working hours. Active causes of failure or medication error include incorrect choice of medication or route of administration, and failure of memory or attention.64
Studies have identified the most common medications administered wrongly. They include vasopressors, opioids, and cardio-stimulants.65 A study by Llewellyn66 from South Africa reported the most frequent cause of error as being due to mislabeling of drugs. Sakaguchi also suggested that most errors were attributable to inexperience of the practitioner involved in drug administration.65 This issue was emphasized in many other studies, including one by Phillips, which correlated increased errors and the start of the new medical residents placement/rotation.67
The Journal of Patient Safety reported incorrect medication as causing nearly half of medication errors (48%), followed by incorrect or excess dosage (38%), and inappropriate route of administration (8%). Smaller 13contributions of 4 and 2% respectively were attributable to administration of less dosage or missing out entirely.68 The analysis further involved breakdown of causes for administration of incorrect medication as syringe swap in 42%, drug ampoule swap in 33%, and wrong choice of medication in 17%. Incorrect and excess dosages were administered frequently due to misunderstanding of dosage, wrong usage of syringe pump (21%), and incorrect use of dilution (5%).53
Detailed breakdown of the actual process during which medication errors are most common revealed some interesting data.69 Administration of any medication in intensive care units involves well over a hundred little steps, right from prescription to administration and monitoring. Though administration is usually double-checked between two medical personnel, it was the most common step for error (53%), far more than prescription (17%), preparation (14%), or transcription (11%). The commonly involved medications include heparin, potassium chloride, inotropes, and antibiotics, which are possibly the most commonly used medications in intensive care unit.
Analysis of medication errors in anesthetic practice70 reported events as occurring more frequently during the maintenance phase of anesthesia (42%) as opposed to induction (28%) or when surgery is commenced (17%). Errors in administration of anesthetic agents could involve route or order of administration or the actual dosage. The usual medications associated with these errors include induction agents, anticholinergics, opioids and neuromuscular blocking agents, among others. An impressive study by Phillips67 also suggested similar causative factors including incorrect dose (40.9%), incorrect medication (16%), and incorrect route (9.5%).
Another analysis of over 2,000 medication errors in anesthesia from Australia also showed 61% events occurred during the administration of drugs. Most commonly, it was administration of wrong drug that was implicated, but in about 7% it was a correctly labeled syringe with wrong drug in it. Miscommunication during provider change was identified as the cause of error.71
An important and not uncommon cause of medication errors is medications that have similar packaging, appearance, or labeling, but very different pharmacological properties, as alluded to earlier. Examples abound of medications packaged similarly with potential for confusion and error, and anesthesia specific drugs are overrepresented in this section. The neuromuscular blocking agents, cisatracurium and rocuronium, have different properties including onset and duration but have similar labeling.
While mortality occurs only in a small proportion of medication errors, the effects in many cases can be far reaching for both patients and healthcare professionals. Increased cost to the healthcare system from morbidity, readmission, prolonged hospital stays, lack of confidence, and 14litigation concerns in caregiver as well as damaged public perception are all consequences of these adverse events.
Table 2   Classification of drug errors.
Drawing up drugs and labeling phase
Similar looking vials
Unlabeled syringes:
  • Not checking the label (including expiry date) prior to administration
  • Different concentration in the syringe and incorrect label (incorrect dilutions esp. relevant in pediatric patients)
Drug administration phase
Near misses:
  • Incorrect dose (inadequate or in excess) esp. in pediatric patients
Syringe swap:
  • Wrong route of administration
  • Incorrect timing of administration
  • Omission, repetition, or substitution of drug
Documentation errors
  • Adverse event not recognized or not documented
  • Reluctance among doctors to admit the error
  • Failure to report an error during medication
Dhawan et al.72 simplified the classification (Table 2) of errors as applied particularly to anesthesia practice.
While much work remains to be done in prevention of medication errors, attitudes toward this are most important in determining the success of any strategy. To this end, Ashcroft et al. studied safety culture in community pharmacies across United Kingdom. Attitudes toward safety ranged from a total lack of understanding for the need of any risk management strategies to an integration of risk reduction steps in every process.73 They have classified attitudes toward medical errors as levels 1–5, from mast dangerous to most risk averse. Level 1 or “pathological” includes subjects who view risk management and safety issues as a waste of time. Level 2 is more “reactive” and responds to incidents appropriately, but actually waits for them to occur. Level 3 or the “calculative” group tries to plan in advance and anticipate possible scenarios. Level 4 is more “proactive” in that they are always on the alert, understanding the inevitability of errors, if the guard is dropped. Level 5 is “generative”, incorporating risk management strategies into every process, and constantly working toward risk minimization.
Worldwide efforts are underway in an effort to reduce the burden of medication errors. Bar coding of medications, reconciliation of electronic 15medical records, large labels highlighting high-risk drugs, and similar measures have been proposed and adopted in many institutions with an aim of reducing the burden of error. The reduction in errors was modest, and highlighted the need for finding alternative solutions to these complex problems. Some hospitals such as Virginia Mason have drawn on industry concepts such as Six Sigma to decrease variance and significantly improve safety in medication administration.74
Another example of extrapolating quality concepts from industry is demonstrable at Froedtert Hospital systems in Milwaukee.75 One main project relating to medication errors through the intravenous route elucidated lack of standardization as the most important cause. Six-Sigma approach was applied to identify systems errors and then implement methods to eliminate these errors. The causes highlighted as part of investigation included medication orders not received, defective faxes, lack of oversight, administration of medications on “standard” doses rather than adjusted for weight, and continuing these medications beyond necessary time frame.
Confirmation that errors were more often system issues and not just individual or personal carelessness then produced system solutions. Intravenous pumps were redesigned with up-to-date information on preparing standard medications, based on industry approach using Six Sigma. This will be the way forward in identifying system failures and suggesting safety measures, though cost is usually a limiting factor. With strong emphasis worldwide on harm minimization and risk reduction, some strategies have been implemented. Some potential systems for safer drug administration include but are not limited to the following:
  • VEINROM: This is a novel design (still in development) for administration of medications intraoperatively, using a predisposition syringe with interlocking mechanism. The acronym stands for vasoconstrictors, emergency drugs, neuromuscular blockers, induction agents, reversal agents, opioids, and miscellaneous drugs. Ports and syringes are color-coded. Bar code facilities allow the medication record to be updated simultaneously with administration.76
  • ValiMed: This validation of medical systems device utilizes photoelectron spectroscopy to confirm the substance being administered when compared with control substance. This tabletop device uses ultraviolet (UV) light for ionization of electrons, and measures the energy of electrons to validate the drug being administered. During an extensive trial by Michigan health system, no drug error was reported during the duration of trial, and also reduced wastage of drugs. Constraints include cost and time required to run the test.7716
  • Robot-assisted medication preparation: With accelerated progress of artificial intelligence and automation, robots are expected to undertake routine tasks of drug preparation and administration. A recent report from Italy (University of Ancona) showed no medication error after 19,000 (95%) chemotherapeutic drugs were prepared using robotic arm aid.78
  • Purchase of prefilled syringes: Some medications are being made available in the form of prefilled syringes, and are anticipated to reduce medication errors significantly. The industry of prefilled syringes is projected to cross 5 billion used.79
Medication errors in the anesthetic scenario can be associated with significant morbidity and mortality. Preparation of premed and anesthetic drugs with appropriate labeling prior to commencement of the case is the first step in anesthetic management. It follows that inaccurate labeling or identification of drugs, distraction and inexperience in a stressful operative environment can result in errors which can sometimes be fatal. Because some drug errors cannot be reversed, prevention is the best way to treat and minimize errors. Terminating services of an individual who commits an error has been commonly seen as effective prevention, though evidence really points to identification and management of system errors.12 Methods for prevention of errors include outsourcing of prefilled syringes, or the cheaper option of preprinted label stickers which can be peeled and stuck onto vials or syringes. Unlabeled vials and syringes should be compulsorily discarded. VEINROM, ValiMed, and robotic preparation/dispensation of medications may gain popularity once they become more affordable.
While accepting that most errors are caused by unintentional mistakes, and are not always associated with bad outcomes, doctors need to be extremely vigilant to avoid these errors. With efforts at prevention, it is also important to report any near miss, so safety protocols can be further improved. This is important in the interest of patient safety as well as reduction in spiraling medicolegal costs. It follows that one of the principal stems in error prevention is education of anesthesiologists regarding the unique risks of their position. Being the only person responsible for prescribing, preparing, and administering drugs; the onus of checking and rechecking really falls on their shoulders. Beside this awareness and education, development of safer and error proof systems needs to be considered as a joint venture between 17anesthesiologists and their institutions. It appears that there continues to be underreporting of medical errors, which then mask the extent and effects of the problem. Cultural differences may contribute to difficulty in acceptance of errors. Finally, these measures, both at individual and organizational level, need to be accepted and implemented.
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