Safety incident reviews: ongoing learning

The following information and recommendations are being shared with all facilities in the spirit of continuous learning, and improving patient safety.

The Non-Hospital Medical and Surgical Facilities Program Patient Safety Incident Review Panel recently reviewed an incident of aspiration pneumonia arising from regurgitation of stomach contents following induction of anesthesia in a patient with an adjustable gastric band in place. 

The contributing factors to this incident included:

  • the patient had an adjustable gastric band (LAGB) in place which may impair gastric emptying of certain foods
  • the patient experienced regular acid-reflux which was treated with ranitidine when needed
  • the patient last ate a fibrous, hard-to-digest food eight hours prior to scheduled surgery and went to bed shortly after food consumption
  • neither a rapid sequence induction (RSI) was used, nor an H2 blocker given preoperatively

In reviewing the potential impact of these contributory factors on the patient safety incident (adverse event), the panel made the following recommendations for the facility and others to consider: that non-hospital facilities be more specific about oral intake preoperatively for those patients with an adjustable gastric band in place. For example, suggesting easily digestible foods and a strict time limit with patients at risk for regurgitation, and that anesthetic technique (RSI) be considered to reduce the complication of aspiration.