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4 Reducing Perioperative Medication Errors: How toBuild Safer Systems
https://t.me/med1917
Table 4.2 Characteristics of high reliability organizations
Characteristic Description
Preoccupation
with failure
Reluctance to
simplify
Sensitivity to
operations
Deference to
expertise
Commitment
to resilience
HROs High reliability organizations
Sources: Weick etal. (2007) [54]; Chassin etal. (2013) [55]
Everyone is aware of and thinking about the potential for failure. People
understand that new threats emerge regularly from situations that no one
imagined could occur, so all personnel actively think about what could go
wrong and are alert to small signs of potential problems. The absence of
errors or accidents leads not to complacency, but to a heightened sense of
vigilance for the next possible failure. Near misses are viewed as
opportunities to learn about systems issues and potential improvements,
rather than as evidence of safety
People resist simplifying their understanding of work processes and how and
why things succeed or fail in their environment. People in HROs understand
that the work is complex and dynamic. They seek underlying rather than
surface explanations. While HROs recognize the value of standardization of
workows to reduce variation, they also appreciate the complexity inherent in
the number of teams, processes, and relationships involved in conducting
daily operations
Based on their understanding of operational complexity, people in HROs
strive to maintain a high awareness of operational conditions. This sensitivity
is often referred to as “big picture understanding” or “situation awareness.” It
means that people cultivate an understanding of the context of the current
state of their work in relation to the unit or organizational state—i.e., what is
going on around them—and how the current state might support or threaten
safety
People in HROs appreciate that the people closest to the work are the most
knowledgeable about the work. Thus, people in HROs know that in a crisis or
emergency the person with greatest knowledge of the situation might not be
the person with the highest status and seniority. Deference to local and
situation expertise results in a spirit of inquiry and de-emphasis on hierarchy
in favor of learning as much as possible about potential safety threats. In an
HRO, everyone is expected to share concerns with others, and the
organizational climate is such that all staff members are comfortable speaking
up about potential safety problems
Commitment to resilience is rooted in the fundamental understanding of the
frequently unpredictable nature of system failures. People in HROs assume
the system is at risk for failure, and they practice performing rapid
assessments of and responses to challenging situations. Teams cultivate
situation assessment and cross-monitoring so they may identify potential
safety threats quickly and respond either before safety problems cause harm,
or by mitigating the seriousness of the safety event
63
Organizational Leadership andCommitment
toMedication Safety
Patient safety should be clearly stated as an organizational goal, and resources must
be devoted to maintain a viable safety program and create clear metrics and goals.
The Crew Resource Management (CRM) program was developed by the aviation
industry and extrapolated to healthcare practice to improve patient safety, including
medication safety [56]. It includes: (a) building the team in charge, (b) improving
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P. Khoury and U. Usta
teamwork skills, (c) stress and conict management training, (d) enforced code of
mutual respect and prohibit intimidating behaviors, (e) encouraging interdisciplinary awareness and education, (f) providing simulations, trainings, and recurrent
trainings about clinical scenarios; and (g) using essential checklists in complementary role to teamwork.
Effective Process Improvement
The third key domain for reliability is the effective process improvement for medication safety plan. Failure modes and effects analysis, or a gap analysis, is the key
step to identify causes of failures of safety processes and put in place an action plan
using robust process improvement (RPI) tools. The Institute of Healthcare
Improvement has a failure mode and effect analysis (FMEA) interactive tool, [57]
and the AORN released an adult medication safety assessment [58]. RPI is dened
as the blend of Lean Six Sigma plus formal change management and commitment
to clear goals or outcomes supported by clear action.
Lean Six Sigma is a set of tools that identies and removes wasted effort from a
process and focuses on reducing the defects in a process (dene, measure, analyze,
improve, and control). The Joint Commission applied the RPI tools with teams from
hospitals, and the rates of improvement demonstrated were consistent with other
industries that applied the same tools [55, 59] (e.g., 81% of hand hygiene compliance after implementation versus 47.5%).
Summary
An interdisciplinary team—with signicant representation from anesthesia, nursing, surgery, and pharmacy—should lead efforts to provide staff education and
maintain and improve medication safety in the perioperative environment.
This chapter highlighted the recommendations of professional and safety organizations APSF, ASHP, AORN, and Joint Commission. These recommendations are
based on standardization, technology, pharmacy services, and establishment of just
culture around medication safety reporting and sharing the lessons learned.
Organizations can use the information in this chapter to assess safety gaps in
their current perioperative workows and processes. RPI tools are useful to dene
relevant improvement initiatives, to track the progress based on specic metrics to
design systems, and to prevent errors from occurring.
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4 Reducing Perioperative Medication Errors: How toBuild Safer Systems
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event/sentinel- event- alert- newsletters/sentinel- event- alert- 57- the- essential- role- of- leadershipin- developing- a- safety- culture/. Accessed 20 July 2019.
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67
Managing thePatient onAntiplatelet,
https://t.me/med1917
Anticoagulation, Beta Blockers,
Angiotensin-Converting Enzyme
Inhibitors, Angiotensin-Receptors
Blockers: TheAnesthesia Perspective
CynthiaKaram, WissamMaroun, andMarieT.Aouad
Introduction
Patients on anticoagulants and/or antiplatelet medications scheduled for elective or
urgent surgical procedures may pose major clinical dilemmas throughout the perioperative period. Deep vein thrombosis prophylaxis, as well as primary or secondary prevention of cardiac or cerebral events with anticoagulants or antiplatelet
therapy are very common scenarios in patients presenting for surgery. Withholding
such medications is not without risk, which itself varies depending on the primary
condition for which the medications are prescribed. On the other hand, maintaining
such therapies may exacerbate the risk of perioperative bleeding. Patients receiving
hemostasis-altering drugs are often considered high-risk patients. This may add an
additional layer of complexity since neuraxial anesthesia may be favored over general anesthesia in this particular group of patients. However, hemostasis-altering
drugs put the patients at a higher risk for spinal hematoma, a devastating complication that can cause irreversible neurological damage. The combination of surgical as
well as patient-related perioperative risk factors may result in a wide spectrum of
complicated clinical scenarios. A number of guidelines were issued to serve as a
frame of practice during the perioperative period. However, level A evidence is
lacking in this eld with, at best, level B evidence in the form of observational and
epidemiologic series. When data are sparse, level C evidence is derived from expert
opinion and newer anticoagulant pharmacological models or kinetics. Most of the
time, recommendations favor patients’ safety and are rather conservative. As such,
these guidelines do not dene standard of care. Sound clinical judgment tailored to
5
C. Karam · W. Maroun
American University of Beirut Medical Center, Beirut, Lebanon
M. T. Aouad (*)
Department of Anesthesiology, American University of Beirut Medical Center,
Beirut, Lebanon
e-mail: mm01@aub.edu.lb
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_5
69
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specic clinical scenarios should be exerted and may sometimes result in deviation
from recommendations.
The management of medications in the perioperative period does not only concern drugs involved in coagulation hemostasis. Preexisting hypertension imposes
the challenge of managing antihypertensive medications perioperatively. These
patients are more likely to experience intraoperative blood pressure lability, which
may lead to myocardial injury [1]. Adequate blood pressure control must be maintained in the perioperative setting, as its instability is associated with increased mortality, especially in the elderly population [2]. The goal is to maintain mean arterial
pressure within acceptable ranges. To help achieve this measurable goal, management of antihypertensive medications, mainly angiotensin-converting enzyme
(ACE) inhibitors and beta blockers, is a crucial part of the perioperative assessment.
In the rst half of this review, we will present an overview of the following
themes: patients on anticoagulants/antiplatelet medications scheduled for surgery
under regional/neuraxial anesthesia, patients with recent cardiac stents undergoing
non-cardiac surgery, and patients on chronic anticoagulation presenting for surgery.
The second half will cover the management of antihypertensive medications in the
perioperative period.
C. Karam et al.
Regional Anesthesia inPatients Receiving Anticoagulants
andAntiplatelet Medications
Incidence andConsequences ofSpinal Hematomas
Hemorrhage within the spinal neuraxis is a devastating complication of spinal or
epidural anesthesia or analgesia. Although it is difcult to have an accurate estimation of the magnitude of the problem, the calculated incidence derived from observational series [3] is approximated to be less than 1in 150,000 epidural and less than
1in 220,000 spinal anesthesia cases. The risk associated with epidural analgesia for
labor (1in 200,000) is signicantly less than in elderly women receiving epidural
anesthesia for knee arthroplasty (1in 3600) [4]. Also, the risk of spinal hematoma in
elderly women receiving spinal anesthesia for hip fracture is higher compared with
the risk of hematoma associated with spinal anesthesia in the general population
(1in 480,000) [4]. In the presence of additional risk factors, such as anticoagulation,
the incidence of this complication is expected to become higher. Spinal hematoma
remains a rare occurrence. Nevertheless, its consequences are devastating unless
prompt diagnosis and intervention are initiated. Risk factors for spinal hematomas
include the presence of coagulation abnormalities or hemostasis- altering drugs, in
addition to the presence of spinal pathologies and needle or catheter placement difculties [4–6]. Furthermore, the risk seems to be higher with an epidural anesthetic,
especially when a catheter is used as compared to a single-shot spinal anesthetic. In
the presence of risk factors, bleeding in the epidural space may occur during catheter
placement, but also during catheter removal. Therefore, clear time intervals between
stopping hemostasis-altering drugs and epidural instrumentation are dened for both
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
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insertion and removal of the epidural catheter. A motor decit is the most common
initial manifestation of spinal hematomas, rather than back pain [5, 6]. In the setup of
postoperative epidural analgesia, the confounding sensory and motor effect of local
anesthetics can be confusing and may lead to a delay in the diagnosis of the neurologic decit. Therefore, it is recommended to use dilute local anesthetic mixtures that
would yield motor sparing, in addition to careful and frequent neurologic examinations. An early diagnosis and intervention are key for neurologic recovery. The
shorter the interval between the onset of symptoms and surgical decompression, the
better the neurologic outcome. For instance, a cutoff interval of 8h resulted in the
largest proportion of good neurologic outcome in the series of spinal hematomas
reported by Vandemeulen etal. [5]
Vascular puncture during a peripheral nerve block is not a rare event; the incidence could be as high as 5.7% and 6.6% for femoral and sciatic catheters, respectively [7]. The use of ultrasound guidance has certainly led to a decrease in the rate
of vascular puncture [8]. Yet, even with the risk of vascular puncture, signicant
bleeding and serious complications are rare. For instance, among 405 patients who
received an axillary peripheral nerve block, only one patient developed hematoma,
and that patient was on heparin [9]. Patients on anticoagulation may be at higher risk
for hematoma development; however, there are no randomized controlled trials that
specically address this topic. Few case reports reported the occurrence of hematomas after catheter removal on patients treated with enoxaparin postoperatively [10,
11]. Nevertheless, major bleeding complications do not seem to be common during
peripheral nerve blocks. Despite this reassuring fact, the relatively scarce data leads
to the application of a conservative approach when a peripheral nerve block is contemplated in a patient receiving anticoagulation/antiplatelet therapy.
71
Effect ofRegional Anesthesia onPostoperative Outcomes
With the ever-growing proportion of elderly and high-risk patient populations, the
number of patients receiving hemostasis-altering drugs presenting for surgery is on
the rise. Respecting recommendations and guidelines regarding the acceptable time
intervals between withholding these drugs and the performance of neuraxial anesthesia may result in delays of the surgical procedure, a time constraint that can by itself
pose an additional risk factor for perioperative morbidity and mortality. For instance,
conning an elderly patient with a hip fracture in bed waiting for the effect of anticoagulants or antiplatelet therapy to fade away in order to perform the hip surgery under
spinal anesthesia may predispose the patient to a different set of morbidities and complications [12]. A clear understanding of the potential benets of neuraxial or regional
anesthesia (RA) over general anesthesia (GA) in terms of improved perioperative outcomes is required to be able to establish the most appropriate and evidence-based
anesthesia plan. The choice of the anesthetic technique and its impact on postoperative outcomes remain a source of debate. RA results in improved analgesia as compared to GA with systemic opioids; however, its association with additional outcome
benets is less clear [13–15]. Beyond reducing acute postoperative pain, evidence
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suggests that epidural analgesia reduces post- thoracotomy chronic pain [16]. Surgeries
conducted under peripheral nerve blocks result in less postoperative nausea and vomiting [17]. A clear reduction in pulmonary complications and, subsequently, intensive
care unit admissions, are demonstrated with the use of epidural analgesia for abdominal, thoracic, and lower limb surgeries in patients with preexisting lung disease [15,
17]. The duration of postoperative ileus is also reduced with epidural analgesia [18].
Conversely, the impact of RA is less clear on the reduction of cardiac morbidity, postoperative cognitive dysfunction, reduction in cancer recurrence, and mortality [18].
When contemplating a neuraxial anesthesia technique in the presence of hemostasisaltering drugs, a clear benet-to-risk ratio has to be determined.
C. Karam et al.
Management ofHemostasis-Altering Drugs inPatients Receiving
Neuraxial or Peripheral Nerve Blocks
As previously mentioned, no solid evidence that dictates the management of
hemostasis- altering drugs in patients receiving neuraxial or peripheral blocks is
available. Hence, pharmacological and physiological properties are used as guiding principles where evidence is lacking [19]. In the presence of therapeutic anticoagulation, it is assumed that ve half-lives are needed to allow the resolution of
97% of anticoagulation effect (assuming normal kidney function and metabolism).
Accordingly, subsequent neuraxial or peripheral block can be safely performed
ve half-life post-discontinuation of the drug [19]. The same concept applies for
prophylactic anticoagulation, yet with a different time interval of two half-lives
instead of ve being required [19]. For patients on anticoagulation who need
peripheral/neuraxial catheter removal, one has to take into account not only the
pharmacokinetics of the given drug, but also the time needed to form a stable platelet plug that is somehow resistant to lysis by anticoagulation. It is estimated that
approximately 8h are needed for a platelet plug to become stable [20]; the safe
time that would reduce the risk for bleeding post-catheter removal is calculated by
subtracting the time to peak effect of the given drug from 8h [21]. For example,
given that the peak effect of low molecular weight heparin (LMWH) is 4h, the
time to subsequent dosing following catheter removal would be 4h (8h−4h). Of
note, recommendations are usually given with time intervals rather than exact
durations in order to account for normal variations in pharmacological activity.
Patients with altered metabolism, such as a renal failure patient receiving a kidneyexcreted medication may need longer time intervals than healthy individuals. Other
factors, including patient characteristics (history of bleeding/bruising, medical
comorbidities increasing the risk of bleeding) and the type of procedure (deep
versus supercial block, continuous versus single injection technique) should also
be considered. A summary of the major recommendations for specic medications
based on the current evidence, and the major guiding principles, is presented in
Table5.1 [19]. Recommendations for neuraxial blocks and deep peripheral blocks
are interchangeable [19]. Supercial peripheral blocks management is based on
site compressibility, vascularity, and consequences of bleeding should it occur [19].
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
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73
Table 5.1
antiplatelet therapy, undergoing regional anesthesia [19]
Medication
Apixaban 72h At least 6h 26–30h 6h
Aspirin No restrictions No restrictions No restrictions No restrictions
Bivalirudin Avoid Avoid Avoid Avoid
Cilostazol 2days 6h, avoid with
Clopidogrel 5–7days Immediately if
Dabigatran 5days 6h, avoid with
Enoxaparin
BID,
prophylaxis
Enoxaparin
QD,
prophylaxis
Enoxaparin,
therapeutic
Fondaparinux No
Heparin IV 4–6h and normal
Heparin SC,
prophylaxis,
high-dose BID
and TID
Heparin SC,
prophylaxis,
low-dose BID
and TID
Heparin SC,
therapeutic
NSAIDs No restrictions No restrictions No restrictions No restrictions
Prasugrel 7–10days Immediately if
Summary of the recommendations for the management of patients on anticoagulant/
Restart after
Hold before
neuraxial/deep
peripheral block
12h 12h Avoid 4h
12h 12h 12h 4h
24h 24–72h Avoid 4h
recommendation
coagulations
status
12h and
assessment of
coagulation
status
4–6h or
assessment of
coagulation
status
24h and
assessment of
coagulation
status
neuraxial/deep
peripheral
block
indwelling
catheter
no loading
dose, 6h if
loading dose
indwelling
catheters
Avoid Avoid 6h
1h 4–6h and normal
Unknown risk;
risk/benet
assessment
required
Immediately 4–6h Immediately
Not
recommended
during
indwelling
catheter
no loading
dose
Hold before
neuraxial/
peripheral
catheter removal
Avoid 6h
Keep catheters for
1–2days after
restarting if no
loading dose
34–36h, or dTT/
ECT testing
coagulation status
Unknown risk;
risk/benet
assessment
required
Not recommended Immediately
Avoid Immediately if no
Restart after
neuraxial/
peripheral
catheter removal
Immediately if no
loading dose, 6h
if loading dose
6h
1h
Immediately
loading dose
(continued)
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