Anesthesia is a prerequisite for the smooth operation of patients and is a high-risk department, which has been defined by the WHO as "the second global safety challenge." With the rapid development of medicine, anesthesiology has also made great progress, and the scope of anesthesiology practice has also expanded rapidly. Although anesthesia technology has shown great progress with the development of medical technology, the increased difficulty of surgery and the increase in the age of patients undergoing surgery as well as the increase in the number of critically ill patients have placed higher demands on the safety of anesthesia[6, 7]. Although adverse anesthetic events are unavoidable when performing anesthetic operations or using anesthetic drugs, Arbous et al. concluded that strengthening the routine management of anesthesia can reduce anesthetic risks.
Adverse anesthesia events are a collective term for anesthesia accidents, anesthesia errors, anesthesia accidents and anesthesia complications. Among them, anesthesia accident is a human error, such as technical fault, paralysis and laxity, which occurs when an anesthesiologist performs operation or management, and the patient suffers from disability, dysfunction and organ tissue damage, while anesthesia error is a situation in which the patient's pain is increased or the treatment time is prolonged due to the skill or negligence of the anesthesiologist, but no serious adverse consequences occur. Compared with anesthesia accidents, the results caused by both are different. Anesthesia errors can also be divided into two categories: general errors and serious errors, in which general errors refer to anesthesiologists who cause certain pain to patients due to technical negligence or negligent behavior. Serious errors, on the other hand, refer to the negligent behavior or technical fault of the anesthesiologist, which causes pain to the patient and prolongs the hospitalization period and treatment time of the patient. Anesthesia accidents are unexpected and dangerous situations caused by the special effects of drugs, intraoperative stimulation and individual differences of patients, which may cause serious consequences such as death; anesthesia complications are adverse symptoms that occur in patients due to anesthetic drugs or operation methods. How to avoid and reduce the occurrence of adverse events and "effective and safe" anesthesia is the eternal theme of anesthesia work. From the actual work, we seriously summarize the mistakes and shortcomings in anesthesia work, implement the system of reporting anesthesia adverse events without responsibility, take this as an opportunity to strengthen the routine management and safety quality control of anesthesia, and promote the continuous improvement of anesthesia quality. The whole department will take the initiative to report the adverse events or safety hazards encountered in their work and rectify them in the form of PDCA. Adverse events that occur or are discovered by one person will enable the whole department to learn to avoid them and take them as a warning so that they will not repeat the mistakes.
In this article, we analyzed 589 patients with adverse anesthesia events and found that the occurrence of adverse anesthesia events was related to the patient's age, anesthesia ASA classification, time, and anesthesiologist's seniority, but not to the patient's gender, duration of surgery, or anesthesia method. Inadequate anesthesia preparation, unskilled anesthesia and improper anesthesia management were the main reasons for the occurrence of adverse anesthesia events in patients. In terms of age of occurrence, the proportion of elderly patients was higher, which may be related to the older the patient, the longer the duration of the disease, and the poorer the body tolerance; while the proportion of anesthesia grade II and III was significantly higher than that of grade I, IV, and V, which may be related to the proportion of surgical patients of grade II and III in the hospital; the proportion of induction period and awakening period was higher, which may be related to the type of surgery, preoperative preparation, and the difference in the physical condition of patients. This may be related to the type of surgery, the adequacy of preoperative preparation and the difference in the physical condition of patients.
The main reasons for the occurrence of adverse anesthetic events include the following: ① Patient factors. With the continuous advancement of anesthesia and surgical techniques, the age range of recipients has been relaxed and the number of critically or acutely ill patients has increased. And these patients often have more concurrent diseases, which to a certain extent increases the riskiness of anesthesia and the probability of adverse anesthetic events. ② Surgical factors. The increase in the number of complex surgeries and the expansion of the scope of surgery have led to long operating times, trauma, and bleeding, which have increased the difficulty of maintaining the stability of the intraoperative internal environment. ③ Anesthesia factors. Anesthetic drugs are characterized by difficult dose control, rapid onset of action, and high toxicity, which is one of the causes of adverse events in anesthesia. In addition, there are more traumatic operations, such as arterial static puncture, block anesthesia, tracheobronchial intubation, etc., which may cause the occurrence of adverse anesthesia events. ④ Human factors. Reason pointed out that human error includes two basic elements: manifest and potential factors. Among them, explicit factors refer to factors that directly lead to the occurrence of errors, such as failure to use the checklist before anesthesia, errors or omissions in safety check steps, incorrect judgment of the patient's lesion that leads to incorrect treatment, failure to wash hands before operation, and violation of medical operation routines. Potential factors, on the other hand, are somewhat hidden, mostly within personnel or institutions, and are generally more difficult to identify, but can be reflected by a lack of multiple aspects, such as excessive workload, poor management skills, and inadequate staff communication. Potential factors generally need to be discovered through in-depth exploration, and should be given sufficient attention.
In order to reduce the incidence of adverse events in anesthesia and improve the safety of anesthesia, our department has developed corresponding safety management measures, including: ① The establishment of an emergency expert group in the Department of Anesthesia. Many of the consequences of adverse events in anesthesia are relatively serious, and once they occur, if they are not handled properly or misjudged they may delay resuscitation and cause great harm to the patient, or even death. Therefore, risk anticipatory thinking should be established to minimize the risk of anesthesia. To this end, an anesthesiology emergency expert group can be established to be specifically responsible for the prevention and treatment of adverse events in anesthesia. The head of the expert group can be the head of the department, and its members include physicians above the attending level in the department of otorhinolaryngology and emergency medicine, experienced nursing, and physicians not involved in this department, with 5 to 15 members, whose duties include assessing the degree of cerebral hypoxia in patients, arranging for resuscitation personnel to perform relevant resuscitation work, giving disposal advice, implementing subhypothermia therapy, correcting acid-base, checking blood gases, and other specific tasks. At the same time, a workbook is developed and emergency plans are formulated in advance according to daily work, etc. ② Good documentation of the anesthesia process. A complete and true record of surgery and anesthesia is an important condition to ensure the safe management of anesthesia, so "always record" should be done in the process of anesthesia implementation, including preoperative induction, tracheal intubation, intraoperative medication, patient vital signs, etc. If adverse events occur, regardless of whether the patient causes serious harm to the patient, they should be strictly recorded. However, attention should be given to ensure the objectivity of the record, and try to avoid modification, and if it must be modified, the modification time should be indicated. ③ Strengthen the preoperative and postoperative follow-up. Preoperative visits were strictly performed to understand the patient's surgical condition and plan from the physician in charge, and patients with contraindications were excluded. At the end of surgery, patients may still have complications or other anesthesia-related adverse conditions after anesthesia wakefulness, so postoperative visits should be strengthened to closely understand the changes in patients' signs and symptoms, so that early detection of abnormalities can be handled in a timely manner. ④ Regular anesthesia emergency training. Each type of adverse anesthesia events lead to different consequences; if not handled properly, inaccurate judgment may lead to the occurrence of delayed resuscitation, resulting in aggravation of the patient's injury. Thus, the risk awareness of anesthesia staff should be established to strengthen the prevention of adverse anesthesia events. ⑤ Establish a long-term mechanism for anesthesiologists. Anesthesiologists should be selected to participate in advanced studies in hospitals at home and abroad to better introduce new ideas and techniques and improve the comprehensive strength of anesthesiologists. At the same time, the access system is strictly implemented to screen out anesthesiologists who are skilled in all operational skills and have strong emergency response capabilities. It is also very important for anesthesiologists to cultivate medical ethics and medical styles. Therefore, while learning new knowledge and techniques, anesthesiologists should strengthen their own moral cultivation to form good medical ethics. Anesthesiologists are required to strictly fulfill the preoperative visit assessment system, to understand the patient's condition and surgical plan from the supervising physician, to exclude patients with contraindications to anesthesia, and to perform ASA grading. In addition, the possible risks in anesthesia can be introduced to the patient before surgery, countermeasures to deal with them can be informed to gain the patient's cooperation or win the patient's understanding and support, and the anesthesia informed consent form can be strictly signed. The anesthesia drugs, anesthesia tools, monitoring equipment and instruments were carefully checked before surgery to ensure that they were in normal condition. ⑥ Strengthen the management of high-risk periods. In our department, the attending anesthesiologist is in charge of the system, so the attending anesthesiologist is required to be on site to observe and guide during the high-risk periods such as induction and awakening of anesthesia, and the rules of anesthesia management are also entrusted to the attending physician or above for implementation.
All adverse events involve more or less anesthesia management factors, such as individualization of anesthetic dose, proficiency of anesthesia operation, and regulation of vital signs during anesthesia. In addition, the nature and severity of the patient's disease, the patient's age, physical condition, and individual differences are also important factors that affect anesthesia safety. Therefore, we should pay more attention to pediatric, elderly and critically ill patients in anesthesia management, and select physicians with higher seniority to perform anesthesia in personnel arrangements. Anesthesia department personnel management should strengthen the basic theory, basic operation and basic skills training, and be strictly required, strictly managed and strictly organized. Therefore, the anesthesia adverse event reporting system provides an evidence-based basis for anesthesia safety management and is conducive to continuous improvement of anesthesia quality. In addition, we should also pay attention to humanistic care, avoid using endotracheal stimulation and wake-up drugs to forcefully wake up patients, and can make them wake up naturally by improving their general condition. We should also give patients the necessary comfort to improve their physiological and psychological reactions during recovery from anesthesia. Only by taking effective anesthesia safety management measures can we reduce the occurrence of adverse events and improve the safety of anesthesia.
There is no uniform voluntary reporting system for adverse events abroad. Some believe that a voluntary reporting system that reports all medical errors and adverse events would greatly contribute to medical safety. There are several advantages to a uniform voluntary reporting system: ① The large number of reports would help prioritize injuries and allow for efficient use of resources; ② The identification and early warning of low-incidence events would allow for early identification of unsuspected injuries; ③ Analysis of many events from different sources would allow for rapid and accurate identification of contributing factors; and ④ Lessons learned could be widely shared. Despite these advantages, there are doubts about the practicality of a unified adverse event reporting system in foreign countries.
Based on the analysis of the existing adverse event whole process management mode, at present, our department relies on the information construction and our self-developed clinical information management system of surgical anesthesia(see Figure 3 for details), and develops and designs a professional adverse event management system by ourselves༈see Figure 4 and 5 for details), which can connect to various hospital information systems (such as HIS system) across platforms and read relevant data, further simplifying the reporting procedure and shortening the time of filling out the reporting form. Scientific use of hierarchical classification analysis method, timely feedback and positive improvement of reported events; the use of improved comprehensive trigger tool detection method, sorting out all the high-risk processes of adverse events, automatic detection of adverse events, reducing the phenomenon of misreporting and omission, thus enhancing the ability of our department to identify, deal with safety hazards and prevent the occurrence of adverse events, and thus promoting the management of adverse events in our department, to achieve safe medical The goal of safe medical treatment. At present, the system has entered the trial stage, before using the system, using manual statistics, generally need 5-10 days to complete the report file, for this reason has to set the monthly adverse event statistics analysis cycle in the 1-10 days of each month, such as May to do the April report cycle for April 1 to May 1, the next 5-10 days for the production of reports and the reported events for classification analysis. However, after using the system, it only takes one hour to complete all the previous workload, which greatly improves the work efficiency.
The next step is to use the information system with related management technology to write programs to realize a graphical interface and further improve the quality of management; the other step is to further improve the whole process of adverse event management with the help of big data, cloud computing and deep learning related machine intelligence technology to reduce the rate of missing and misreporting of adverse events and improve the user experience of those who fill in the report.