Page 14 - Part 2 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

the surgeon, and the primary anesthesia providers if

appropriate, with the patient and/or family)

4. Close that OR for that day; do not turn off or unplug
anything; access any memory in any monitor or device

used (especially the vital signs stored in many OR patient
monitors) and print this out or photograph the screen(s)

if there is no printing capacity; sequester all involved
equipment and supplies (and the trash and needle

buckets) and then:

• Alter nothing (no cleaning, no disassembly, no repair);

if it appears likely or even possible that an equipment
failure (anesthesia machine ventilator, bubble detector

on a rapid infuser, ect.) contributed to an accident,
it may be indicated to conduct an inspection/

testing session involving the real-time participation
of representatives of the involved practitioners, the

equipment manufacturers, the equipment maintenance
personnel, facility administration, and involved

insurance companies/attorneys.

• Discard nothing; sometimes the solution to a mystery

can later be discovered in unexpected tiny details, such
as an empty or missing or extra medication vial that

suggests an accidental wrong drug administration may
have caused the accident.

• Lock away all of the above (this may be difficult
in a busy facility so be reasonable; for example,

if it is accepted by all involved that there was an

unrecognized esophageal intubation involving
apparent human error, it would be possible to release
the OR and its equipment for use the next day and

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