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1. Anesthesia machines may catch fire, Abbott warns 2. IOM report: National networked system would reduce medical errors 3. Pay-per-view: This patient rounds checklist can cut length of stay in half

Patient Safety Monitor Alert, November 26, 2003

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1. Anesthesia machines may catch fire, Abbott warns

Isolated reports have indicated that fire or extreme heat can take place in the respiratory circuit of anesthesia machines, particularly if Ultane® (sevoflurane) is used in conjunction with a desiccated CO2 absorbent, Abbott Laboratories warned in a letter to health care professionals November 17.

The Illinois-based pharmaceuticals company is working with the U.S. Food and Drug Administration to determine the cause of the heat and fire risk. Extreme heat can reduce the anesthetizing effects of Ultane, cause patients to cough, and can result in airway edema, erythema, and high carboxyhemoglobin levels, according to Abbott.

The letter provides suggestions for reducing fire risk associated when using Ultane, an inhaled drug used to induce and maintain general anesthesia in adult and pediatric patients for inpatient and outpatient surgery. The suggestions include:

>> Replace CO2 absorbents that have not been used for an extended period of time. They may have become desiccated, which can increase the risk of fire.

>> Turn anesthesia machines off completely at the end of clinical use or after any case when a subsequent extended period of non-use is anticipated. A low fresh gas flow rate over an extended period of non-use may contribute to unexpected desiccation of CO2 absorbent materials.

>> Monitor the temperature of the CO2 absorbent canisters periodically.

>> Replace CO2 absorbents regularly, regardless of the state of their color indicator. A lack of significant color change does not mean there is adequate hydration.

>> If staff notice excessive heat coming from the CO2 absorbent canister, consider the following interventions to avoid or minimize possible patient injury:

* Disconnect the patient from the anesthesia circuit.

* Shut off fresh gas flow to the breathing circuit or remove the CO2 absorbent canister. * Replace the CO2 absorbent.

* Monitor the patient for carbon monoxide exposure and possible chemical or thermal injury.

Visit the FDA's website for more information.

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2. IOM report: National networked system would reduce medical errors

To significantly reduce the tens of thousands of deaths and injuries caused by medical errors every year, health care organizations should adopt information technology systems that are capable of collecting and sharing essential health information on patients and their care, says a new report by the Institute of Medicine of the National Academies (IOM).

Although some hospitals, pharmacies, and physician practices do use electronic health records, the practice is not widespread and is not networked together. The IOM envisions a huge network that would allow an emergency department in New York City to gain instant access to medical records in Arizona for a patient visiting the city from Phoenix.

Such routine use of electronic health records would give health care providers and patients immediate access to complete patient information as well as tools to guide decision-making and help prevent the tens of thousands of deaths and injuries that are caused by medical errors each year, states the report, "Patient Safety: Achieving a New Standard for Care."

The IOM, which advises the government on medical issues, recommended that the government model such a system after the airline industry's air traffic and weather information systems.

"When it comes to safety, the health care industry needs to borrow a page from the airline industry," said committee chair Paul Tang, chief medical information officer, Palo Alto Medical Foundation, Palo Alto, CA. "Pilots have instantaneous access to the data they need on weather conditions and mechanical functions to make informed decisions about navigation, delays, and midcourse corrections."

While some hospitals, medical groups, and other health care organizations have installed computer systems to manage patient information, a national infrastructure for standardized data collection and exchange is needed because patients often receive services from many different providers, according to the report.

"It is time to shift the emphasis of patient safety programs from a strategy of reporting, focused on injuries after they have occurred, to one of prevention aimed at providing safe and effective care in the first place," Tang said.

A 1999 IOM report estimated that up to 98,000 deaths occur every year in U.S. hospitals as a result of medical errors. Recent studies show that tens of thousands of additional errors occur in nursing homes and clinics.

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3. Pay-per-view: A patient rounds checklist that can reduce length of stay by half

Using a daily checklist to determine and track each patient's goals can boost patient safety by decreasing infection risks and lengths of stay.

That's the conclusion reached by physicians at Baltimore-based Johns Hopkins Hospital, where the surgical oncology intensive care unit (ICU) has used a daily goals form since 2001.

Physicians fill the form out during morning patient care rounds and place it in the patient's chart for the day. As a result, the average length of stay for Johns Hopkins ICU patients dropped from two days to one day, and residents and nurses reported a greater understanding of each patient's goals.

Before using the goals form, fewer than 10% of residents and nurses said they understood their patients' goals of care for the day. After using the form, more than 95% do.

Bonus: Get a free copy of the checklist and learn how ICU staff at Johns Hopkins in Baltimore implemented it when you order this pay-per-view story. The cost is just $10. Click here to learn more.

"Briefings on Patient Safety" subscribers have already read this article. They received it as part of their November 2003 newsletter.

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NEED TO CONTACT US?

Wendy Johnson, managing editor

wjohnson@hcpro.com

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