Can the simple act of changing medication packaging save lives? On this week's Anesthesia Patient Safety Podcast, we uncover the alarming truth about the recurrent and devastating error of inadvertent intrathecal tranexamic acid administration. This episode is a continuation of last week's urgent discussion, featuring insights from Elizabeth Rebello and colleagues, who stress system-focused solutions over human-reliant measures to tackle this critical patient safety issue.

We dissect the human factors contributing to these errors, particularly the look-alike nature of tranexamic acid and local anesthetic ampules. Highlighting prevention strategies, the episode underscores the importance of providing tranexamic acid in pre-mixed bags, aligning with recommendations from the 2010 APSF Stoelting Conference. Listen in as we break down the hierarchy of effectiveness for risk reduction strategies by the Institute for Safe Medication Practices (ISMP), ranging from simple reminders to advanced automation and fail-safes, all aimed at enhancing medication safety in the operating room.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/210-preventing-deadly-errors-unpacking-safe-practices-for-medication-administration-in-the-or/

© 2024, The Anesthesia Patient Safety Foundation

Join us on the Anesthesia Patient Safety Podcast as we confront a critical patient safety issue: the recurring wrong drug, wrong route errors involving Tranexamic acid (TXA) and Bupivacaine. Elizabeth Rebello, an anesthesiologist at the University of Texas MD Anderson Cancer Center, sheds light on this alarming trend where lookalike vials lead to catastrophic outcomes, including paralysis and death. Learn why this issue demands urgent action and the steps that are essential for anesthesia professionals to prevent such devastating mistakes.

We'll uncover real-world incidents and delve into the underlying challenges faced by anesthesia teams, from lack of standardization to high-pressure environments. Hear about the staggering 50% mortality rate associated with this error and revisit our previous coverage on a National Alert Network warning about similar TXA administration errors. This episode is a must-listen for those dedicated to advancing perioperative patient safety and mitigating the risks of medication administration errors in anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/209-preventing-catastrophic-medication-errors-the-dangers-of-txa-and-bupivacaine-mix-ups/

© 2024, The Anesthesia Patient Safety Foundation

Unlock the secrets of enhancing perioperative patient safety with insights from experts in anesthesiology and critical care. Join us as we welcome Dr. Debnath Chatterjee, the editor-in-chief of OpenAnesthesia, who sheds light on the incredible educational resources available on the platform. From peer-reviewed mini-reviews to engaging podcasts and vodcasts, discover how OpenAnesthesia is making a global impact, benefiting both trainees and seasoned clinicians.

We are excited to share one of the OpenAnesthesia Ask the Experts Podcasts on our show today.

Journey with us into the realm of pediatric anesthesia as Dr. Britta Regli-von Ungern-Sternberg and OpenAnesthesia Editor Dr. Jina Sinskey discuss perioperative respiratory adverse events in pediatric patients. Reflecting on the pivotal 2010 Lancet study and the more recent APRICOT study, we explore how anesthesia practices have evolved. Learn about the significant shift towards Total Intravenous Anesthesia (TIVA) and the reduced use of Desflurane, alongside practical recommendations like using propofol for high-risk children and preoperative salbutamol administration to mitigate respiratory risks.

Gain a unique perspective on the challenges faced by Perth’s sole children's hospital, especially in managing pediatric cases involving upper respiratory tract infections, including COVID-19. Through detailed insights, understand the criteria for proceeding with or canceling procedures and the logistical hurdles for rural and remote patients. Emphasizing the importance of experience, communication, and tailored approaches, this episode also navigates the balancing act of pursuing a career in academic medicine. Discover the value of mentorship, the necessity of maintaining personal relationships, and the flexibility required to thrive in both professional and personal spheres.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/208-its-an-openanesthesia-takeover-show/

© 2024, The Anesthesia Patient Safety Foundation

Unlock the essential strategies for ensuring patient safety during anesthesia in the prone position! On this episode, host Alli Bechtel welcomes Taizoon Dhoon, an associate professor at the University of California, Irvine, who shares his expertise from his recent article in the APSF newsletter. Dhoon sheds light on the often-overlooked risks of prone positioning, detailing the physiological changes and positioning injuries that can arise. This discussion is a treasure trove of knowledge for anesthesia professionals, aiming to elevate patient care practices and enhance collaborative efforts among medical teams.

Our journey begins with an in-depth review of recommended practices and preoperative considerations, emphasizing the critical role of thorough exams, patient history evaluations, and cardiac assessments. Discover the actionable steps you can take to improve safety, from pre-surgical planning to additional monitoring during procedures. Whether you're an experienced anesthetist or new to the field, this episode provides the insights and tools you need to navigate the complexities of prone positioning with confidence and precision. Tune in and empower your practice with expert advice and practical recommendations.

We are covering two bonus articles to discuss concerns with the Perifix® L.O.R. syringe (B-Braun, Melsungen, Germany) that is used with the loss of resistance (LOR) technique to confirm the epidural space, and we are diving into the literature. Our literature review summary takes you through the 2023 article, "Comparison of the hemodynamic effects o opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial."

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/207-patient-safety-during-prone-positioning/

© 2024, The Anesthesia Patient Safety Foundation

What if the prone position during anesthesia is more hazardous than you think? Equip yourself with crucial knowledge about the overlooked risks and physiologic changes associated with prone positioning during surgery and procedures. This episode uncovers the some of the dangers such as peripheral nerve injuries, postoperative vision loss, and significant hemodynamic shifts that can endanger patient safety. Our discussion illuminates the necessity for anesthesia professionals to maintain heightened vigilance and adopt preventive measures.

We'll also explore the complex physiologic alterations that occur in the prone position. This episode offers actionable preoperative, intraoperative, and postoperative strategies to mitigate these risks and ensure optimal patient outcomes. By tuning in, you'll gain invaluable insights and practical recommendations to enhance your practice and safeguard your patients during prone surgeries. and. procedures. Don’t miss this essential guide to mastering the challenges of prone positioning during anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/206-enhancing-safety-during-anesthesia-care-in-the-prone-position/

© 2024, The Anesthesia Patient Safety Foundation

Ever wondered about the underappredicated dangers of prone positioning during surgery? Join me, Alli Bechtel, as we navigate the complexities and risks of managing patients in this critical position. From pressure-related injuries to the eyes, nose, and shoulders, to nerve ischemia and shoulder dislocations, we'll cover it all. In this episode, inspired by Taizoon Dhoon and colleagues' article "The Underappreciated Dangers of the Prone Position," we’ll dissect the physiologic changes that can lead to severe complications if not properly managed. This is an essential listen for anyone involved in perioperative care.

Gain practical insights into protecting vulnerable areas and mitigating risks associated with prone positioning. We’ll explore common pitfalls and offer strategies to improve patient safety, including proper limb positioning and adequate padding. Learn about the specific nerves at risk and the physiologic changes affecting ocular health and overall patient well-being. Grab a pen and paper for this detailed discussion on how to safeguard patients and ensure optimal outcomes in the operating room.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/205-safeguarding-patients-navigating-the-dangers-of-prone-positioning/

© 2024, The Anesthesia Patient Safety Foundation

Discover the essential elements of a high-functioning anesthesia care team with our special guest Matthew Sherrer from the University of Alabama at Birmingham. In an episode that could redefine your understanding of teamwork in healthcare, we delve into the phenomenon of 'trust fractures' and their profound impact on patient safety. The authors offer rich insights from his experience, drawing striking parallels between aviation disasters like Korean Air Flight 801 and the critical importance of communication within medical teams. Prepare to be enlightened as we explore the sobering reality of communication failures in healthcare, and learn about innovative initiatives like UAB's Anesthesia Care Team Optimization Committee  aimed at mending trust and bolstering team dynamics for the safety of our patients and wellbeing of healthcare professionals.

In the high-stakes world of anesthesia, the need for a culture that embodies mutual respect, curiosity, and empathy stands paramount. The University of Alabama at Birmingham's Anesthesia Care Team Optimization Committee has been at the forefront, pioneering a collaborative ethos that is transforming perioperative communication. In our conversation, we celebrate the team's triumphs—from implementing novel communication tools and educational sessions to fostering interprofessional cooperation via shared journal clubs. Witness the positive ripples of a collective intelligence model where cohesive teams not only enhance patient outcomes but also enrich healthcare professionals' lives with reduced stress and improved job satisfaction. Let this episode be your guide to cultivating excellence in patient safety and team performance in your healthcare environment.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/204-cultivating-excellence-in-anesthesia-teams-trust-communication-and-patient-safety/

© 2024, The Anesthesia Patient Safety Foundation

Discover how mastering situational awareness can revolutionize your approach to perioperative patient safety in our latest podcast episode. We are joined by David Tscholl, an esteemed anesthesiologist and researcher from the University Hospital in Zurich, Switzerland who unveils critical findings from recent studies in this February 2024 APSF newsletter article. The shocking revelation that 80% of adverse events in anesthesia and critical care are due to errors in situational awareness underscores the urgency of this discussion. This enlightening conversation promises to equip you with the knowledge to enhance your decision-making skills in the high-stakes perioperative environment.

With a deep dive into the concept's origins from aviation psychology to its application in anesthesia care, we dissect the cyclical sequence of perceiving, comprehending, and projecting crucial information for maintaining situational awareness. We also highlight how experience, knowledge, and training can build this critical skill, while cautioning against the negative impacts of fatigue and excessive workload. The episode is enriched with a visual tool in the show notes, helping to illustrate this three-tiered concept and its influence on patient outcomes. Join us for an episode that promises not only to inform but also to transform the way you perceive and react to the ever-changing dynamics of anesthesia patient care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/203-enhancing-perioperative-patient-safety-through-situational-awareness/

© 2024, The Anesthesia Patient Safety Foundation

Embark on a journey through the interplay of teamwork, civility, and patient safety with our esteemed guests, Matt Sherrer and Mitch Tsai from the Fresh Flow podcast, and emergency medicine savant Chris Turner.  The conversation navigates the treacherous waters of workforce shortages and academic anesthesiology pressures, unearthing strategies to foster a thriving professional climate where mutual respect reigns supreme.

Feel the pulse of our professional interactions as we delve into reputation—your very own "theme tune" that echoes in the corridors of your workplace. We examine the subtle dance between the image we project and the legacy we yearn to build, from the ominous tones of Jaws to the symphony of positive influence. Uncover the critical role of psychological safety in knitting teams tightly together, as we reveal the cognitive cost of incivility's subtlest gestures and advocate for an environment enriched with courtesy and cooperation, ultimately uplifting patient care and collective morale.

Closing on a harmonious note, we contemplate the art of leadership and the quintessence of wisdom in the healthcare cosmos. We spotlight the transformative power of wise leaders who orchestrate a culture ripe for questioning and shared knowledge, instrumental in informed decision-making. Our exploration extends to the tender discussions of end-of-life care, aligning treatments with deeply held patient values. And for a final twist, we engage in a light-hearted riff on the transcendent language of music, comparing the distinctive strums of British and American guitar tones, affirming the melody of our unified pursuit: enhancing patient safety.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/202-teamwork-civility-and-the-quest-for-patient-safety-a-fresh-flow-podcast-takeover/

© 2024, The Anesthesia Patient Safety Foundation

Ever found yourself grappling with the complexities of peripheral nerve blocks and patient safety? This episode is a treasure trove of insights as we unpack the February 2024 APSF newsletter article by the esteemed trio Christina Ratto, Joseph Szokol, and Paul Lee, shedding light on the crucial precautions necessary for regional anesthesia procedures. Get ready for an enriching conversation with Paul Lee, Division Chief of Regional Anesthesia and Clinical Assistant Professor of Anesthesiology at Keck Medical Center, as he shares valuable personal experiences and stresses the need for meticulous safety checks.

Navigate through the nuances of handling emergencies, like dealing with seizures or arrhythmias associated with LAST, with confidence. We cover the must-know local anesthetic systemic toxicity checklist, providing concrete steps and dosing recommendations to ensure patient stability in a crisis. This is more than just another clinical discussion; it's about arming yourself with the knowledge to elevate patient care to the highest standard. Join us for an episode packed with actionable takeaways for any anesthesia professional dedicated to the noble cause of patient safety.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/201-enhancing-regional-anesthesia-practices-for-superior-patient-safety-part-2/

© 2024, The Anesthesia Patient Safety Foundation