Anesthesia Complications in the Dental Office

Robert C. Bosack, Stuart Lieblich

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118828670
• Edition: 1
• Topic: Medicine
• Subtopic: Oral Health & Surgery

Anesthetic complications, which range from simple annoyances to patient mortality, are inevitable, given the many and complex interactions of doctor, patient, personnel, and facility. Anesthesia Complications in the Dental Office helps dentists minimize the frequency and severity of adverse events by providing concise and clinically relevant information that can be put to everyday use. Anesthesia Complications in the Dental Office presents the most up-to-date information on treating anesthesia complications and medical emergencies. Drs. Bosack and Lieblich and a team of expert contributors discuss patient risk assessment; considerations for special needs and medically compromised patients; routinely administered anesthetic agents; adversities that can arise before, during, and after administration of anesthesia; and emergency drugs and equipment. A must-have reference for every dental office.

Section 1

Introduction

Chapter 1
Anesthetic complications—how bad things happen

Robert C. Bosack

University of Illinois, College of Dentistry, Chicago, IL, USA

The delivery of anesthesia in any setting is not without risk. The environment is complex, uncertain, and ever-changing. Human performance of this potentially hazardous task can be unpredictable and imperfect, especially in times of urgency, intensity, and time pressure. Risk and human error cannot be eliminated, but can be reduced and managed by eliminating a culture of blame and punishment and replacing it with a culture of vigilance and cooperation to expose and remediate system weaknesses, which, in combination, often lead to error and injury.

The concept is straightforward. Most patients do not enjoy going to the dentist. Although patients understand that pain can be eliminated with local anesthesia, fear and anxiety still fuel avoidance of necessary care. Dentistry has responded to these issues by providing options for various levels of sedation, analgesia, or general anesthesia in the dental office. Usually, all goes well. Patients are satisfied; necessary dental work gets done. Sometimes, however, things do not go well.

Complications (adverse events, sentinel events) are defined as unplanned, unexpected, unintended, and undesirable patient outcomes: death, physical/psychological injury, or any unexpected variation in a process or outcome that demands notice. Errors are deviations from accuracy or correctness, usually, caused by a fault (mistake) for example, carelessness, misjudgment, or forgetfulness. Most errors have no obvious effect on patients, yet most (82%) preventable complications in the past involved human error (Cooper et al., 1978).

Errors are categorized according to persons or systems (Reason, 2000). Person approach refers to individual human error: forgetfulness, inattention, lapses (temporary failure of memory), preoccupation, violation (conscious deviation from a rule), loss of situational awareness, and fixation errors. Human errors lead to specific technical, judgmental, or monitoring mistakes, examples of which are given in Table 1.1. System approach refers to practice conditions: staff training, equipment, schedule density, health history gathering, policies, procedures, checklists, and so on. Latent errors can lay dormant in practices for years, only to be exposed during a triggering event, which then leads to an adverse outcome in a susceptible patient.

Table 1.1 Triggering events

Technical Drug overdose Failed airway management technique Oxygen source disconnection Equipment failure Judgmental Inadequate patient history Wrong drug/technique Wrong airway management technique Delay or failure to adequately treat abnormality Monitoring/vigilance Failure to detect abnormality Failure to accept abnormality Alarm “saturation”

Although it is tempting to blame a complication on a single human error (e.g., the practitioner gave the wrong drug and the patient died), seldom is this the case. Most complications are now known to be due to an unfortunate temporal alignment of a series of errors, which results in injury. These errors can arise from multiple sources, which include latent errors (overbooking, failure to update medical histories, failure to check equipment, lack of training, poor communication), psychological precursors (fear of lawsuit, embarrassment), system defects (staff not trained in emergency protocols, failure to use checklists, failure to update medical emergency drugs), triggering factors (loss of airway, unintended drug overdose, hypotension, etc.), atypical conditions (key staff member absent), and outright unsafe acts (lack of knowledge, errors of the moment, ignoring a monitor, failure to address a problem, wrong drug given, etc.)

Scope of Errors

Unfortunately, errors are a normal part of human behavior, and their causes are not obscure. Habit intrusion, stress, anger, fatigue, boredom, fear, time urgency, illness, and haste increase the odds of faulty performance.

The extent of errors documented to have contributed to anesthetic complications is great. All six major areas of anesthetic practice are implicated: inadequate pre-anesthetic evaluation, faulty patient selection, poor anesthetic management, inadequate monitoring, hurried recovery, and faulty recognition and inappropriate management of complications. Specific examples of errors are noted in Table 1.2.

Table 1.2 Examples of Anesthetic Errors (Cooper et al., 1984)

Loss of oxygen supply (tanks empty, not turned on, tubes disconnected) Drug error – wrong drug, wrong dose, syringe swap (unlabeled) Wrong choice of airway maintenance Careless, lack of vigilance haste Faulty information gathering and assimilation Lack of preparation, scenario rehearsal Poor communication among team members Unreliable intravenous access Unfamiliarity with drugs

The Human Condition

Homo sapiens is the only species that understands the concept of risk; however, habituation blunts this worry. The sense of having control over risk feeds the illusion of preparedness and prompts feelings of denial...

Table of contents

• Cover
• Title Page
• Copyright
• Table of Contents
• Dedication
• Contributors
• Foreword
• Preface
• Acknowledgment
• Section 1: Introduction
• Section 2: Patient Risk Assessment
• Section 3: Anesthetic Considerations for Special Patients
• Section 4: Review of Anesthetic Agents
• Section 5: Monitoring
• Section 6: Preparation for Adversity
• Section 7: Anesthetic Adversity
• Section 8: Post-Anesthetic Adversity
• Section 9: When Bad Things Happen
• Section 10: When should you say no
• Section 11: Appendices
• Index
• End User License Agreement