KoreAnesthesia 2021

PBLD 1	Decision making for unanticipated moderate valve dysfunction discovered intra-operatively	Course introduction

PBLD 2	Making sense of root cause analysis investigations of anesthesia-related adverse events	Course introduction

PBLD 3	BASILICA procedure during TAVI	Course introduction

PBLD 4	Echo guiding in transcatheter mitral edge to edge repair	Course introduction

PBLD 5	Mediastinal mass and airway compromise	Course introduction

PBLD 6	TEE for Intraop decision making	Course introduction

PBLD 7	ROTEM interactive case discussions	Course introduction

PBLD 8	Hemodynamic management	Course introduction

[PBLD 1] Decision making for unanticipated moderate valve dysfunction discovered intra-operatively

Date, Time & Language

Nov 5(Fri) 09:00 – 10:00, English

Place

Hybrid (Online + Room D) - Access details will be sent to the registrants.

Moderator

Nikolaos Skubas (Cleveland Clinic, USA)

Instructor

Charles Nyman (Brigham and Women's Hospital, USA)

Panel

Youn Joung Cho (Seoul National University, Korea)

Jin-Tae Kim (Seoul National University, Korea)

Joungmin Kim (Chonnam National University, Korea)

Jeong-Jin Min (Sungkyunkwan University, Korea)

Karam Nam (Seoul National University, Korea)

Learning objectives

At the end of this PBLD session, participants should have an approach to the unanticipated finding of

Moderate Mitral regurgitation

Moderate Tricuspid regurgitation

Moderate Aortic Stenosis

Moderate Aortic Regurgitation

Description

This will be a case based PBLD focusing on case examples with unanticipated findings intra-operatively, will provide clinical decision-making steps and available guidelines to guide the decision making process. Will provide mechanisms for audience members to ask questions and provide responses to clinical scenarios.

Key cases / problems

Unanticipated intra-operative findings of

Moderate Mitral regurgitation

Moderate Tricuspid regurgitation

Moderate Aortic Stenosis

Moderate Aortic Regurgitation

Useful material

If there is any further material or information would like to share with your potential PBLD audiences and for dynamic session, please feel free to send us with an attachment or type here.

[PBLD 2] Making sense of root cause analysis investigations of anesthesia-related adverse events

Date, Time & Language

Nov 5(Fri) 11:00 – 12:00, English

Place

Hybrid (Online + Room D) - Access details will be sent to the registrants.

Moderator

Justin Sangwook Ko (Sungkyunkwan University, Korea)

Instructor

Paul Barach (Thomas Jefferson University, USA)

Panel

Geunjoo Choi (Chung-Ang University, Korea)

Ha Yeon Kim (Ajou University, Korea)

Ho-Jin Lee (Seoul National University, Korea)

Seokyung Shin (Yonsei University, Korea)

Jae Hee Woo (Ewha Womans University, Korea)

Learning objectives

The learning objectives include (1) reviewing the basic structure of an RCA (eg, main components and how it is done), (2) how to do an initial understanding and final event flow diagram, (3) how to collect information for RCA (eg, interviews), (4) how to do cause and effect diagramming to obtain actionable items (eg, fishbone diagram), and (5) how to develop actions to address underlying causes of anesthesia related system failures, and (6) learn to write a summary of the RCA to engage the key surgical and management leaders in improving the reliability, patient safety and quality improvement of your practice.

Description

CASE: A 15-year-old boy underwent elective right knee arthroscopy and debridement under general anesthesia with a laryngeal mask airway (LMA). He was otherwise healthy with no allergies to medications. After uneventful induction of anesthesia, the surgeons requested antibiotic prophylaxis with cefazolin 1 gram, which the anesthesiology team administered. Just before the surgical incision was made, 50 mcg of Fentanyl was administered. About 2 minutes later, spontaneous respirations slowed, and the patient became apneic. The surgeon and anesthesiologist assumed the patient’s apnea was due to opiate sensitivity and assisted ventilation by hand for 30 minutes. However, despite a rise in the end- tidal CO2 to 70mm Hg, spontaneous respirations did not return.

While current initiatives and collaborative practices strive to make patient care safer, adverse events still in anesthesia care continue to occur. Patient harm is often a consequence of medical errors, which can involve system-based mistakes, including missed or delayed diagnoses, miscommunication between care teams, invasive procedures gone awry, and misadministration of medication. The resulting impact on patients can range from no harm to death. Root cause analysis (RCA) is a structured approach to the investigation of patient safety incidents that is commonly applied in many modern health systems worldwide, particularly in acute hospital settings. It builds the foundation for a safety management system which is underpinned by high-reliable organizational (HRO) approaches. HRO adhere to 5 core principles: (1) sensitivity to operations and how they affect the organization; (2) reluctance to accept simple explanations and striving to identify the root source of problems; (3) preoccupation with failure including anticipating and correcting potential problems before they occur; (4) deference to individuals with expertise of the particular task at hand, regardless of hierarchy; and (5) commitment to resilience, and adaptive when developing new solutions to unexpected problems. As a result, major harm events in HROs are rare. When applied to perioperative systems, a culture of safety means identifying the systematic causes contributing to patient harm, encouraging error reporting and removing individual blame, and promoting multi-level collaboration to develop solutions that may prevent similar errors from happening again. There are existing tools intended to support this process, such as root cause analysis (RCA). Anesthesiology clinicians in particular are key drivers for improving perioperative care, but many lack experience or knowledge in the use of such systems-based practices or quality improvement and patient safety (QI/PS) methodologies, including how to conduct an RCA. Although RCA has been promoted as both tangible evidence of high reliability and an important tool for improving patient safety, literature suggests that execution of RCA within perioperative care is often suboptimal. One leading cause of this is a lack of knowledge and skill of personnel carrying out the RCA. A well-facilitated RCA team engages in a rich social form of clinical simulation through the opportunity to enact conditions that other people and other (local) systems have to cope with. Knowing one’s clinical workplace and making sense of how the organization fits together and functions is perhaps a more reasonable goal than drafting more rigid rules and policies for preventing errors and controlling anesthesia practice risks. This PBLD draws on the experience of facilitating more than 100 RCA investigations.

Key cases / problems

Tjia, Imelda MD; Rampersad, Sally MB, FRCA; Varughese, Anna MD, MPH;. et al. Wake Up Safe and Root Cause Analysis, Anesthesia & Analgesia: July 2014 - Volume 119 - Issue 1 - p 122-136 doi: 10.1213/ANE.0000000000000266.

Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002;28:531-545.

Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422.

Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: what does the literature tell us? Jt Comm J Qual Patient Saf. 2008;34:391-398.

Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf. 2012;21:369-380.

Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London Protocol. Clin Risk. 2004;10:211- 220.

Card AJ, Ward J, Clarkson PJ. Successful risk assessment may not always lead to successful risk control: a systematic literature review of risk control after root cause analysis. J Healthc Risk Manag. 2012;31:6-12.

assin B, Barach P. Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events. Surg Clin North America 2012, 1-15, doi:10.1016/j.suc.2011.12.008.

Conclusions

Medication-related adverse events are a frequent cause of patient morbidity and mortality in perioperative care, and must be better understood in order to prevent medication harm.

Incident investigation following an adverse perioperative event requires an organizational and departmental safety culture that fosters open dialogue surrounding medical errors to maximize organizational learning.

Root cause analysis is only one of many methods of incident investigation. Newer methods promote a systemic view of incident investigations and analysis.

Incident investigations in health care need to be conducted by professionals skilled in human factors engineering and systems thinking, alongside expert clinicians and frontline staff.

The recommendation phase should receive more attention. Perioperative corrective actions need to be congruent to the causal factors they are trying to address and monitored for successful implementation and risk mitigation.

Problems identified through root cause analysis cannot be solved by individuals but require coordinated efforts across the entire health care system.