AHRQ WebM&M: Morbidity and Mortality Rounds on the Web
No BP During NIBPA man with atrial fibrillation underwent ablation in the catheterization laboratory under general anesthesia. The patient was extremely stable during the 7-hour procedure, with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems, making this a near miss. Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc, both of the University of British Columbia, discuss safety hazards associated with patient monitoring during anesthesia and offer recommendations such as decision support alerts to prevent errors.
No BP During NIBP
Commentary by Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MScthe case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anesthesia. The procedure lasted 7 hours. Per American Society of Anesthesiologists guidelines, monitoring included continuous electrocardiography, oxygen saturation, end tidal carbon dioxide, as well as noninvasive blood pressure (NIBP) measurement every 5 minutes. The patient was extremely stable with values hardly changing over time. Inadvertently between 4 PM and 5 PM, the NIBP stopped "cycling," but this was not recognized. When the attending anesthesiologist took over the case at the end of the certified registered nurse anesthetist's (CRNA) shift, she noticed that the "graphic trends" tab on the monitor had a straight line for heart rate and oxygen saturation (indicating no change over time) and a blank space for the NIBP. A lookup of numerical trend was done and it showed that the last NIBP recording was more than 60 minutes earlier. After discovering the error, the case continued without any problem. The patient was extubated and discharged home the next day as planned. The patient was informed about the mistake and he accepted it as human error.
Reviewing the case revealed that certain safety checks that are routine in the operating room (OR) do not routinely occur in the cardiac catheterization laboratory setting in this hospital. First, OR attending physicians are expected to frequently check the progress of the case. Second, the automated anesthesia record in the OR shows "blank" if there are no new NIBP recordings. Third, the OR doctors' work area has a central monitor feed that the attendings watch when they do paperwork. Fourth, the OR monitors "gray" out NIBP value if the cuff is not cycling. These features are not in place for out-of-OR cases. In addition, the monitor for the catheterization laboratory was a different make and model from those in the OR, and the CRNA was unfamiliar with the menu and knobs. The anesthesia record was manual, and the CRNA kept documenting the same reading for a whole hour. Human factors such as fatigue and lack of vigilance in a very stable case also contributed to the error.
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