Page 17 - Part 2 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

suggestions as indicated.

• Be visible, supportive, and not defensive with all
involved.

• Communicate as much as possible (see number six).

Emphasis in current literature is shifting toward Crisis Resource
Management principles, frequent drills or simulation of

emergency situations, and use of cognitive aids. One example is
the Emergency Manual Implementation Collaborative.
4

Accidents and mishaps with anesthesia and in the OR will

continue despite any and all best efforts to prevent them.
Organized preparation and resources may contain injury to a

patient and prevent injury to later patients. Additionally, timely
investigation and documentation will be crucial to determine

cause of the injury and to develop a prevention strategy. Care
providers should not bypass the opportunity to learn from

mistakes, but an ounce of prevention, as the old saying goes, is
worth a pound of cure.

Intra-operative Burns

Fires account for many MAC claims and are more common
during surgery on the head, face and neck. In most all

cases with burns, an electrocautery tool is being used with
supplemental oxygen supplied via a nasal canula, face mask, or

face tent.

Surgical fires are rare, but serious events. Operating room fires

occur about 600 times a year. The FDA started a Preventing
5

4 http://emergencymanual.stanford.edu/emic.html
5 https://www.aana.com/practice/clinical-practice-resources/surgical-firesb

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