Page 26 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

that requires more room for adequate documentation, a

supplemental narrative can be useful as an addition to the
anesthesia records. If you are ever called upon to defend your

care and treatment, it is better to have a record that reads
“narrow complex bradyarrhythmia unresponsive to atropine”

than one that says, “patient coded, resuscitation performed”.
The care of the patient always comes first, but you should write

the narrative while the events are fresh in your mind especially
in the event of an unexpected outcome.

The failure of the anesthesiologist to document his or her

presence in the operating room for induction and emergence
led to allegations of improper CRNA oversight in several of the

claims. The anesthesiologist must be available during these
times, and his or her availability should be noted in the record.

The position of patients during anesthesia, padding, and eye
protection is an essential responsibility of the anesthesiology

team. Allegations of nerve damage leading to permanent
disabilities cannot be defended as successfully with insufficient

notes.

Taking a time-out prior to blocks or placing arterial lines is a
vital patient safety and team coordination measure. Your active

involvement in the time-out is to verify the patient’s identity,
to check the consent for the correct procedure, correct side,

correct site, and correct position. Organize time-outs for any
anesthetic blocks. If multiple surgeons are performing multiple

procedures, a time-out should take place before each one, and
these should be well-documented in the record.

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