Page 58 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

 During resuscitation efforts, cardioversion paddles that

had been left uncharged delayed resuscitation attempts
and again contributed to a poor outcome

Although an intraoperative anesthesia catastrophe is unlikely,

the anesthesiologist/CRNA must be prepared. The Adverse
Event Protocol that was first published in The Journal of

Clinical Anesthesia in 1993 (and still relevant today) provides a

plan of action to combat the lack of knowledge and
experience.
22

By the end of the 1980s, the creation and universal application

of the strategies of intraoperative anesthesia safety monitoring
were in effect, and the anesthesia catastrophes became even

rarer. Continuous patient and anesthesia delivery system

monitoring with the addition of electronic monitors permitted
minute-to-minute monitoring of patient oxygenation and

ventilation. As a consequence, the anesthesia team was
alerted to potential problems that have, in the past, led to

patient injury and catastrophe. The alarm itself indicated how
to resolve the potential mishap before actual injury occurred.

As a result, the frequency and severity of intraoperative

patient-injury accidents decreased dramatically. Thus, a
significant component of the previously traditional training and

experience of anesthesia practitioners was functionally

eliminated.

22 Organized Response to Major Anesthesia Accident Will Help Limit Damage, Eichhorn, John H.,
APSF Newsletter Vol. 21, No. 1, Spring 2006, https://www.apsf.org/article/organized-response-to-
major-anesthesia-accident-will-help-limit-damage/

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