Safety incident reviews: sharing learning

An incident review team visited the facility to work with staff to understand what happened, identify contributing factors and make recommendations for improvement.

The contributing factors to this incident included:

  • Anesthesiology’s use of longer-acting opioids during surgery, non-reversal of neuromuscular blockade following surgery, and patients arriving in the PACU intubated.
  • The type of surgery. Shoulder surgery is typically associated with significant post-operative pain and therefore patients are at higher risk for respiratory depression and decreased oxygen saturation due to post-operative analgesic needs.
  • PACU staff consideration of the opioids and local anesthetic, given in the OR, and when they will take effect when making decisions about the administration of additional analgesia in PACU.

In reviewing the potential impact of these contributory factors on the patient safety incidents, the panel made recommendations for the facility and others to consider including:

  • Anesthesia should carefully consider the choice and dose of intra-operative narcotics and reverse all neuromuscular blockade.
  • Anesthesia should endeavour to limit the number of patients arriving in the PACU intubated and for those who do arrive intubated the length of time to extubation should be minimized.
  • PACU staff must be aware of the types and amounts of opioids and local anesthesia given in the OR, and adjust the analgesic dosing in the PACU accordingly.
  • Post-operative pain medication orders should be patient-specific. When using preprinted order sets, not every drug should be selected for every patient.