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Cases & Commentaries
- Web M&M
Jeanna Blitz, MD; November 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
Perspectives on Safety > Perspective
with commentary by Jeffrey B. Cooper, PhD, Reflections on the History of the Patient Safety Movement, August 2006
My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...
Journal Article > Commentary
Runciman WB, Kluger MT, Morris RW, Paix AD, Watterson LM, Webb RK. Qual Saf Health Care. 2005;14:e1.
This study describes the development of specific algorithms in clinical anesthesia to address crisis situations. Using the first 4000 reports from the Australian Incident Monitoring Study (AIMS), a team of anesthetists identified a need for 24 algorithms. Investigators created a manual to outline the management approaches and tested it against the incidents from AIMS. The authors conclude that applying these algorithms in daily practice should be considered as decision support when a clinical scenario evolves in an unexpected fashion. This article serves as an introduction to a set of 24 resources that outline structured approaches to crisis management in anesthesia.
Journal Article > Commentary
Runciman WB, Merry AF. Qual Saf Health Care. 2005;14:156-163.
This commentary discusses the many facets of crisis management in anesthesia care. The authors describe a previously published crisis management algorithm, explain why providers can fail to respond to crises appropriately, and highlight how precompiled responses and algorithms serve as useful aids. They advocate increased team-oriented training, regular review of devised algorithms, and consideration of similar algorithms in other clinical areas to optimize management of crisis situations. This commentary is accompanied by a manual of 24 specific sub-algorithms in anesthesia crisis management.
Journal Article > Study
Weller J, Merry A, Warman G, Robinson B. Anaesthesia. 2007;62:122-126.
The investigators observed anesthetists in a simulated environment and analyzed their ability to respond to a central oxygen supply failure.