Description of the Innovative Activity

The innovation began with a critical review of adverse events data from several years across many NAPA institutions to explore trends and patterns. The data analysis revealed key risk factors presenting in key populations or risk groups with some common shared patient characteristics (i.e., high body mass index). The NAPSI team selected five specific high-risk scenarios and then spent time reviewing expert recommendations and practice guidelines to develop risk mitigation strategies based on best practices. The resulting five high-risk clinical scenarios focus on patients with (1) known or suspected difficult airways in patients undergoing general endotracheal anesthesia, (2) a high body mass index (greater than or equal to 45) who are undergoing general anesthesia, (3) pulmonary hypertension, (4) a physical status classification of 4 or 5 according to the American Society of Anesthesiologists (ASA), and (5) high risk for an operating room fire.¹ A risk mitigation strategy was then designed in response to the five clinical risk scenarios to form the basis of the Anesthesia Risk Alert program. The three risk mitigation strategies associated with one of each of the five high-risk clinical scenarios mentioned above are:

1. Ensuring a second practitioner is present for induction and emergence.
2. Engaging a second practitioner in discussion.
3. Preparing a detailed risk mitigation strategy per the institution’s policy.¹

After reviewing these best safety practices, the team realized there was an overlap in recommendations for collaboration with an additional provider (even if consultation was remote). Discussing treatment plans before taking action permitted control for potential cognitive bias or any rigidity to practice protocols. The NAPSI team found that consultation with a second practitioner allowed clinicians to better consider the complexity of a case, which led to improved clinical decisions. The NAPSI team also found that conducting a difficult or high-risk procedure with a secondary practitioner present led to better outcomes. Case collaboration with a second practitioner became a common cultural practice that staff complied with even outside of the five high-risk clinical scenarios. The NAPSI team noticed that this case consultation or collaboration, regardless of expertise level, and whether with a junior or senior clinician, broke down power differentials by creating a protocol to make the practice comfortable for all staff.

The NAPSI team designed the Anesthesia Risk Alert program around the five clinical risk scenarios and trained the clinicians to deploy a recommended risk mitigation strategy. Along with this protocol, the Anesthesia Risk Alert program teaches clinicians the rationales underpinning why this collaboration with a secondary clinician is effective in reducing adverse events and improving patient safety. Finally, the NAPA PSO workgroup created a 15-minute training video to teach the Anesthesia Risk Alert program to all staff and kick off implementation in all NAPA facilities.

The NAPSI team constructed this innovation by looking to other fields in which safety is also the focus. The innovation was designed to align with three principles that support the use of a second clinician to improve clinical decisions: Pat Croskerry’s dual process model of reasoning, cognitive biases, and red team/blue team methods. The dual process model of reasoning involves clinician recognition of decisions using both intuitive (fast-thinking) and analytical (slow-thinking) processes to make better decisions.¹ Many experts believe that cognitive biases involved in clinical decisions can lead to errors and patient harms. Consulting with a second clinician is a strategy to avoid these biases.¹ The red team/blue team method comes from the fields of military and cybersecurity testing. It uses an adversarial red team against the incident-responding blue team by running hypothetical scenarios to challenge aspects of the program with the goal of preventing harmful events.¹ The combination of these three principles supports the rationale for collaboration central to this innovation.

Context of the Innovation

Anesthesia is a complex practice domain that is very technical and skill-based.² Although many anesthesia providers are pioneers in the field of patient safety, errors and adverse events still happen.³,⁴ An adverse event is any injury due to medical management rather than the underlying disease, which can lead to poor patient safety outcomes.⁵

The NAPSI team designed a protocol that is nimble and flexible to care as it happens instead of only identifying problems after they occur.¹ The innovator designed their innovative Anesthesia Risk Alert program with strong communication, collaboration, and literature-supported practices to mitigate risks before an adverse event happens.

Results

The NAPSI team documented a steady increase in the Anesthesia Risk Alert program compliance rates and an overall downward trend in adverse events for patients in two of the five high-risk clinical scenarios. The NAPSI team does not collect data about patient history of pulmonary hypertension or any known or suspected difficult airways. Because this patient information is not gathered and documented on all patients, the NAPSI team could not calculate an incidence rate to track change over time in these two high-risk clinical scenarios. Similarly, the NAPSI team noted seven total operating room fires over the study period but also was not able to track nor therefore measure a change in the rate of fires over time. Specifically, the team observed the number of adverse events in all patients with a body mass index at or above 45 receiving general anesthesia (intravenous and inhalation) decreased by 30.7%. The team also observed a 67.7% reduction over a two-year period in the incidence rate of adverse events for patients with ASA 4 or 5 classification. While the research design did not include randomization or test for a causal relationship between the application of the Anesthesia Risk Alert program and decreases in adverse events, the Innovation team did observe an inverse relationship over time according to their quality reporting platform and their Microsoft Power BI dashboards.

The NAPSI team has reported that staff routinely apply risk mitigation strategies, and that implementation of the Anesthesia Risk Alert program caused a change in staff behaviors that increased communication and collaboration. Collaboration techniques improved decision-making among the anesthesia team (from preoperative staff to postoperative staff) by establishing communication with another anesthesia provider to discuss and review the case and the treatment plan. Some collaborations involve a discussion, and other collaborations have a colleague present during critical moments of the anesthetic administration to support and lend a hand in addition to expertise. The Innovation team found that teamwork increased outside of the Anesthesia Risk Alert program scenarios. NAPA clinicians have reported that their preoperative and surgical nursing teams collaborate routinely with them now in advance of any known hazard because the nurses recognize patients’ high-risk factors and consider whether mitigation strategies could be applied.

Planning and Development Process

Key steps in planning and implementing the innovation:

• Seek organizational support and the dedication of resources to collect data analytics on adverse events.
• Review data on adverse events.
• Identify a team of experts to review clinical guidelines and evidence-based practices to mitigate the adverse events.
• Have experts design risk mitigation strategies per each high-risk clinical scenario
• Be inspired by other safety disciplines and industries by creatively innovating your safety practices.
• Design an implementation plan.

Resources Used and Skills Needed

• Coordinator to orchestrate and implement the innovation across providers.
• Dashboards to drive conversations in monthly quality meetings.
• Data-driven talking points shared at monthly quality meetings.
• Data dissemination methods via texts and emails to providers to encourage ongoing documentation and increases in compliance.
• Monthly staff meetings conducted by leaders with providers to discuss compliance strengths and gaps, and to give data-driven feedback.
• Data analysis of adverse events.
  • Investing resources into strong data collection and data analytics supported the NAPSI team’s ability to identify their five high-risk clinical scenarios to decrease adverse events.
• Expertise to perform data analytics and to design information technology dashboards (to track compliance and adverse events in Microsoft Power Business Intelligence).
• Clear documentation of adverse events in a NAPSI quality reporting platform.
• Compliance tracking of patient screenings for the five high-risk scenarios. When a positive screen occurs, documentation of whether or not the mitigation strategy was applied.
• Leadership to manage implementation and ongoing feedback to providers.

Funding Sources

The Anesthesia Risk Alert program exists under NAPA’s component Patient Safety Organization, the NAPA Anesthesia Patient Safety Institute (NAPSI).

Getting Started with This Innovation

The first step to implementing the Anesthesia Risk Alert program is securing the necessary resources to build the data infrastructure. Next, examine the adverse events data to find problem areas (i.e., medication error, wrong patient identification) and consider what potential interventions could be applied to mitigate the problem. Then, for each high-risk population, establish a process to make formal recommendations to implement an ongoing intervention to mitigate the issue. Finally, educate staff on the risk groups and the interventions. Also, use ongoing data tracking to track compliance with the program and to observe for a decrease in adverse events until desired outcomes are reached.

Sustaining This Innovation

A key to sustaining this innovation is as follows:

• Establish and continue to emphasize that risk mitigation requires teamwork, and as such, focus on collaborative care.
• Support clinicians as adaptive professionals who must constantly be nimble and accommodating of variations in clinical scenarios.

Footnotes

1. Lee B, Marhalik-Helms J, Penzi L. Anesthesia risk alert program: a proactive safety initiative. Jt Comm J Qual Patient Saf. 2023;49(9):441-449.
2. Mitra M, Basu M, Shailendra K, Biswas N. Risk reduction in anesthesia and sedation-an analysis of process improvement towards zero adverse events. J Family Med Prim Care. 2020;9(9):4592-4602.
3. Stephenson M. Safety II: A practice approach to positive outcomes. Published online January 17, 2023. Accessed January 30, 2024. https://www.hopkinsmedicine.org/news/articles/2023/01/safety-ii-a-proactive-approach-to-positive-outcomes#:~:text=Safety%2DI%20is%20an%20important,focusing%20only%20on%20negative%20outcomes
4. Neily J, Silla ES, Sum-Ping SJT, et al. Anesthesia adverse events voluntarily reported in the Veterans health administration and lessons learned. Anesth Analg. 2018;126(2):471-477.
5. Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-1700.