 Good morning, everybody, and welcome to another Patient Safety Movement Foundation webinar. I'm Donna Crosser, Chief Clinical Officer here at the Patient Safety Movement. Today, we're going to talk about highly reliable safety interventions for anesthesia medication administration. We have some great objectives that we're going to get to, a fabulous panel talking about, you know, what are the evidence-based medication safety recommendations that we are all challenged with implementing an anesthesia. All of the different workspaces, attitudes, and team workflows that are unique to anesthesia and can impact the success of these implementation projects. How pharmacy can help to enhance safe medication practice and what are some recommendations for anesthesia professionals in the future so that we can rapidly adapt to these system-wide medication safety recommendations. So welcome, and we're, as always, very happy to be able to provide continuing education credit for this activity. Nurses, pharmacists, and physicians are approved for one contact hour through our partner MedStar Health. If you registered as a physician, nurse, or pharmacist, you will receive an email from MedStar Health with instructions on how to complete the evaluation so that you can collect that credit. So if you have any questions, please let us know, but you'll probably receive that email anytime within the next several days, but it can take up to five to seven days. We also are offering one credit hour for healthcare executives, which if you can just log into your account at ACHE. For certified professionals in patient safety, you'll receive a certification from a certificate from the Patient Safety Movement Foundation if you registered using that credential. And if you are looking for credit for certified professionals in healthcare quality, then you will receive information from NACU on that. We will send them your information if you registered that way. So as you can see here, none of our panelists or the members of our planning committee have any financial disclosures for today. So with that, I am very excited to hand it over to our moderator. David Kuntz is a certified respiratory or registered nurse anesthetist. He's also a doctor of nursing practice candidate at the University of Central Florida and has been working with us here at the Patient Safety Movement Foundation for the last couple of semesters and we're so excited to have him here to kick off this presentation. So David, I'll hand it over to you to introduce our panelists. Thank you, Donna. Anesthesia medication safety is an important topic for me as a frontline provider. We have had a lot of changes here in the last one to three years, both by pharmacopoeia and also by regulation. And so it's a great time to bring an expert roundtable discussion together and how we start to move and adopt this to the frontline teams and facilities. With that in mind, I would like to introduce Michael Dehos from the United States, Samar Khalid Hassan from Jordan, and Yannica Mela Olsen from Norway. Mike, go ahead and give a little bit of a background here about you. Well, thank you so much, David, Donna, and members of the Patient Safety Movement Foundation. I'm just so excited to chat with you all today. So I serve as the System Medication Safety Officer for Methodist Labaner Healthcare. We're a six-hospital healthcare system based out of Memphis, Tennessee. And I also hold an adjunct assistant professor or faculty position with the University of Tennessee Health Science Center. So thank you again for having me. Samar. Thank you, David. Thank you, Donna. Thank you, the Patient Safety Movement Foundation. I am Samar Khalid Hassan from Jordan. I work in Healthcare Accreditation Council. Jordan and the region's Health Institution for Quality Improvement and Patient Safety. I am really excited to join our panel of experts today to discuss this very important topic. Today, I'll be wearing three hats, the hat of a pharmacist, the hat of a quality professional, and most importantly, the hat of a patient advocate. So I'm looking forward to a great discussion. Thank you. Samar, thank you very much. And now I'd like to introduce Yannika. Hey, everybody. I'm Yannika Mellin-Ousen, as you heard from Norway. I'm a practicing anesthesiologist and I'm also the immediate past president of the World Federation of Societies of Anesthesiologists, representing hundreds of thousands of anesthesiologists in 150 countries. In addition to that, I'm involved in patient safety on the local, national, and European stage, as well as a member of the Board of Director of the Patient Safety Movement Foundation. Honored to be here. Thank you, Yannika. Kind of to give the audience a breakdown of how we're going to flow today. We're going to kind of talk about current problem state, move into the backgrounds, followed by kind of assessment and what is happening now. And then lastly, we will move on to recommendations and how the audience can take that back to their current facilities with a question and answer session. So we'll move right now into what is kind of the current problem and hear from the panelists' perspectives around the challenges with anesthesia and medication safety. Mike, we'll begin with you. Thanks, David. Well, there's so many different challenges and barriers to medication safety as it relates towards anesthesia. If you think about it, the medications that our anesthesia providers administer are what we call high alert medications. And what high alert medications are, they're medications that, when involved in an error, have a greater likelihood for harm. And so those include things like opioids, they include things like paralytics, sedation agents, and more. And because they have a high propensity for harm, if involved in an error, a lot of medication safety officers, patient safety officers are really looking at what are the best error reduction strategies to reduce likelihood for harm. We see that over the past five, 10 years, there's been a great wealth of knowledge that's been developed. There's new antidotes that are ill. There are newer ways to monitor things like automated dispensing cabinets, which hold medications out on the floors. But although that there's all these great advances, we have to recognize there's some opportunity costs associated with them, and that we as clinicians and healthcare leaders need to explore how can we create forcing functions, constraints, and automation. Thank you, Mike. Samar, can you kind of expand on that a little bit too? Yeah, I'd love to ventilate on that. I think Mike described it beautifully. We're all very well aware of the fact that medication errors are the leading cause for patient harm in health systems. However, if we zoom in on anesthesia medication specific, we can see that it's very vulnerable, very complex, very error prone service, yet it operates on fewer medication safety strategies than any other patient care area in the hospital. And that's very interesting. And we need to take a pause and reflect on the vulnerability of the anesthesia services. How can we implement safety strategies like Mike addressed? And most importantly, we see a very alarming number of errors reported from anesthesia medication services. We see fatal harm happening to patients. So we need to focus on that. We need to understand why this is happening. It happens in developed countries. It happened in low to middle income countries. We need to understand the flows and the system. We need to just look at the fabric of anesthesia service and recognize the weakest links and try to address them. Thank you, Samar. Janneke, how do we bring system wide adoption in anesthesia with anesthesia medication administration? Well, I think when it comes to administration of anesthesia medications, it depends on where you are in the world, of course, but the common for all of us is as has been said that the medication we use are very powerful and potent, that they have the possibility to kill patients if we make mistakes with them. And I think all anesthesia providers are very well aware on that, but they live in under circumstances that makes it more difficult to provide medication safely. For instance, there are only one. They are in the room, many places. They are in a hurry. They don't have time. Sometimes situations are emergency situations. And there are so many factors that add to the complexity and adds to what we are that we are prone to make errors of medication. There are many other aspects which we will come back to, but I wanted to highlight those in the first place. Thank you. Kind of combining all of that, moving into the challenges associated with best practice implementation in anesthesia, we kind of touched home on structural, cultural, and processes. Mike, how do we build in the targeted medication strategies? Well, there are all sorts of best practices out there. And one of the organizations that I always look towards is the Institute for Safe Medication Practices. They routinely update their targeted med safety best practices and they highlight what organizations can do to reduce risks in all sorts of areas. In the latest version of the targeted med safety, targeted medication safety best practices by the ISMP, there's a number of things that we could really hit on. And those include things like automated dispensing cabinet overrides, the use of the drug library for smart infusion pumps, especially in those anesthesia care settings. And there's also some great recommendations about how do we segregate and limit the amount of paralytic agents that are available out on the floor. So if I could just dissect those real quick. In the United States, there's a whole movement where a lot of medication safety officers, directors of pharmacy, chief nurse officers, et cetera, where they're looking primarily at medications that are overridden from automated dispensing cabinets. And if you think about it, when we obtain these medications from these machines by way of override, we are bypassing a physician's order or an anesthesiologist order. We are oftentimes bypassing pharmacies involvement to review and verify the appropriateness of that order. And we're bypassing various clinical decision support tactics that are offered within the electronic health record. They check for things like drug-drug interactions, allergies. They look for dose optimization. So that's one aspect. So we always encourage organizations across the United States and really the world, if you are employing and utilizing automated dispensing cabinet, please consider taking an approach to routinely monitoring those. The American Society of Health System Pharmacists, we worked on this a couple of years ago. There's some great resources out there that can help organizations determine what medications should be on override versus not. And so there's a really neat decision tree. The second topic that has been really hit hard amongst various medication safety officers, primarily in the United States, but very much applicable across the world, would be the lack or the limited use of the drug library, primarily in anesthesia settings. If you think about it, these are medications that are coming to be administered intravenously into our patients. And for that reason, we need to see how can we safely administer these to our patients and use the appropriate technology wherever possible. Organizations spend a lot of great time building the drug library, maintaining various types of dose limits, rate limits, etc. And so what we need to do is always encourage and support the use of the drug library for our colleagues. And then the last recommendation I want to really highlight on is limiting the amount of paralytic agents. Now, if a paralytic agent is prepared in those cases, emergently, by an anesthesiologist, I think that's fine because it's going to be usually administered directly to the patient. What worries me, though, is certain hospitals, certain areas will have these paralytic agents, yet they're not oftentimes monitored and there's no segregation or there's no limitation on those. So we always recommend organizations to say, how can we limit the amount of paralytic agents on the floor and also how do we determine its location? Thank you, Mike. I think you really hit home on the key of today's message for our audience. Taking a look with your local team components and looking at those automated dispensing carts and how those medications are separated and how the team utilizes the workflow. Samar, kind of building on that, how do we take a look culturally and processes when we take a look at the framework of the Swiss cheese model? Yeah, great question. Thank you, David. I think I want to circle back on the challenges that you mentioned in the structure of the anesthesia service and then in the cultural aspects of it. Now, in the structural aspect, if we look at anesthesia, we see that it's very complex. We have, it's one of the most medication-intensive locations in the hospital. It has a high alert medication, the use of multiple medication at the same time. Also, you have transitory nature, a lot of hand-offs. The work itself, as Yanake said, it's very stressful. The staff are overworked and fatigued, and you have kind of a lot of distraction, a lot of miscommunication opportunities because you have verbal orders, you have time sensitive tasks. These all are contributing factors to this sensitivity and to the vulnerability of anesthesia service. So if we look at the structure, I think the best way to defect, how can we improve this complex situation is if we look at the Swiss cheese model and we envision that we have a system where error is prone to happen. It's a very error prone area. So if we allow more than one to two errors to happen in consecutive order, and if we don't have the safety barriers in place, we will eventually have results in patient harm. And sometimes, and in most cases, the harm is fatal. That's why we need to recognize the holes in the system, recognize how can we put and implement safety barriers and build the safety net and make it happen in place. As Mike said, we have this kind of issue that the anesthesia provider himself is the same person who select labels, prepares, and administer the medication, the anesthesia medication. That's why we lack the double checking, the second eye system that we often have in other patient care area in the hospital. And this is a very integral component to the vulnerability of the anesthesia system. In terms of culture, I think, I don't know if we have time to expand on that at this point. But I would love to touch on the fact that when we see the recommendation of having an active role for the pharmacist on having dedicated or our pharmacist or having a satellite pharmacy in the operation room, we still see a struggle in the different settings around the world because the pharmacist is really, in the latest days, is trying to have an active role in the clinical side of the hospital. So to have this established role also in the surgical word is not yet a culture that is really strong in some places and it needs to be pushed and it needs to be advocated. So currently the pharmacist role is not yet established in the surgical word, but however, we can still have governance system that guarantee active role for the pharmacist. In terms, like Mike said, in terms of monitoring, the simple act of making sure the labeling is correct, making sure the label is clear can prevent mixing, look alike vials and containers and can prevent syringe swap. The simple act, if we really monitor them and we implement systems for double checking can prevent fatal mistakes. So I think we can still activate the role of the pharmacist, even if we don't have a dedicated or our pharmacist. Thank you, Samar. Mike and Samar, when we talk about the complexity of anesthesia as a frontline anesthesia provider, what I'm hearing is how complex that is. But when we expand that in the barriers to implementation around the world, Janneke, how do we bring the discussion to the table with that? Well, I think I have to just to comment on some of the things that have been said. For instance, when it comes to the double control, because in my setting we are used to doing double control, which is a very helpful thing, but we have another person in the room that can help us. You also have those machines that you can read it out the labels and so on. That's very interesting. And then to another point, which I was thinking about, when you Mike mentioned the paralytic agents, because it's interesting, you have to protect patients from receiving paralytic agents when it's not a good thing. But sometimes if you restrict patients from receiving them, you make it more difficult to get hold of them. Patients that would have benefited from that medications are not receiving them. And then on a global scale, this is a very important problem. For instance, when certain medications are scheduled, for instance, like morphine, which we know the opioid crisis in the United States. But worldwide, the opioid crisis means lack of access to opioids. So for instance, in India, when morphine was controlled, it became so difficult to get hold of morphine in the hospitals, that the pharmacist stopped stocking them because it was so bureaucratic to ask for it. And then when the pharmacist stopped stocking it, there was no production anymore. So the medicinal use of morphine at that time in India, which had a low use of morphine before was dropped by more than 97%. So that's not good for patients either. So we have to keep that balance. Otherwise, I think what has been said about pre-field syringes, very important also to not to have infections, that's a good thing that we can do. And color coding, which is not uniform in the world. Why can we not agree on a uniform color coding, for instance? Also lack of many medications. So if you are lucky, you get a replacement medicine, which is not exactly the same, not good for patients. You have fraud medications, where you buy something from the pharmacy in many countries, which is not what it's supposed to be and so on. It's a very complex thing with so many different aspects, and particularly if you speak about the whole world. Thank you, Yanaka. I think following this, we'll move into what's happening now. And I think because we're hitting home currently on the current culture around how we do error reporting in anesthesia. So, Mark, can you kind of build out on that a little bit? Yeah, sure. I think this situation is kind of unfortunate. Is that in many places we hear about an incident or an error related to anesthesia medication in a newspaper or a headline because it was related to a celebrity of some sort. So the kind of reporting culture is very non-existent. We can say we lack resources, we lack data, and reporting on the incident that happened. The culture of reporting is not very well established. I mean, we say just culture that we need to promote no naming, no blaming, no shaming. However, the culture that we are operating today does not promote and encourage reporting. We have a culture of shooting the messenger rather than rewarding the messenger. We treat errors and incidents as an anomaly rather than we need to treat them as information and learning opportunities. That's very important to work on because an incident in itself or an error in itself is a symptom rather than a condition. And we need to use it as information and dig deep to understand what is leading to that error and where are the holes that are making these errors happen. I mean, if we look at most of the errors, they are mostly human error or at-risk behavior rather than reckless behavior. And at-risk behavior is over-reliance on our experience, our memory, our habits, and especially in anesthesia environment, you have this kind of repetitive design of tasks. So I reach to get this syringe, but if I don't double-check, if I don't read the label correctly, I might end up giving the wrong syringe to the patient. And that's very detrimental that we need to focus on not relying on our experience and our memory and implementing safety strategies and putting them in place so that we can minimize the at-risk behavior. And we need to promote a culture of reporting and a learning system that will be very beneficial to improvement and moving forward. Thank you, Samar. I think building out on culture, Mike, we talk about the institute for safe medication practices and the targeted medication strategies and the tools that can be used in our local facilities and doing an assessment on culture and administration and how do we overcome some of that over and cover barriers and how can local facilities and internationally use the ISMP toolkits? So in addition to ISMP's Target Med Safety Best Practices, there's all sorts of other great resources that they have. You know, we're actually, Methodist Labaner Healthcare, we're participating in ISMP's perioperative self-assessment. And it's pretty neat, actually. It's a 200-point self-assessment. There's all these different recommendations that they have based on their 10 key elements. And what those 10 key elements are, they're essentially different categories of things that could go wrong from a patient information perspective or drug information or you know, clinical education and so forth. So I highly encourage for organizations to do that perioperative self-assessment and then also to do that gap analysis, actually, the of the Target Med Safety Best Practices. And that can be something as simple as going on to a spreadsheet listing out all the different ISMP recommendations. And then on another column, identify what are you currently doing in your own organization. So I think those are probably the best strategies. The other thing that I'd recommend too is in the United States, we also have the American Society of Anesthesiologists and also the Anesthesia Patient Safety Foundation. They've got some really great resources there. So for folks who might not be out of the, might not reside or practice in the United States, please consider using some of those publicly available resources. I do want to touch on and piggyback on some that some are mentioned earlier about overall culture. I think that as we do these different types of gap analyses, these self-assessments, I think the other thing that we as clinicians and leaders who are on this webinar really need to do is identify how can we incentivize or promote better practices of reporting errors in our organization and many other organizations. There's this thing called a good catch award. And what a good catch award is, it's where someone in that environment he or she has intervened on a potential medication error that would have caused great harm to a patient. And what better way to do that great catch award or create that great catch culture than in those anesthesia environments. If you think about it, in those anesthesia environments, there's so many barriers to reporting. And if we develop that climate, that culture of, hey, I've got your back. Hey, I'm here to peer support you. And then find ways to reasonably document that. So individuals in risk, patient safety or quality, they can follow up on that. I think that's where you can get some good wins at it. So from my perspective, I think it's the traditional structure plus process equals outcome. And in doing so, having that culture, which is that overall patient safety culture that supports those structures and processes, that's where you can get the most bang for your buck. Thank you, Mike. Yonika, this is kind of a good time to tie in. We have a question from the audience and how we get buy in and promoting a positive culture through good catch. Yeah, we have how do we gain that buy in from our anesthesia colleagues? I think all of this is very much a leadership responsibility, the leaders. I know from my own, when I was young and so on, my professor, who was my teacher, he would ask all these stupid questions. And he would also tell us about his own mistakes. And I was thinking when he asked all those stupid questions, I mean, he should know that he's a professor. And then later, I found out that the reason why he did so was to make it safe for all of us to expose our problems and so on. So the culture comes from the top. I wouldn't say that the others have no rule in the culture building. But if you have a leader who focuses on that and try and reward this type of behavior to disclose your problems on what you have done wrong, look at errors, how to prevent them and so on. It will go down into the organization. Thank you, Yonika. Thank you, Samar. When we look at the leadership and we take the hierarchical structure and we bring that down to the frontline team members with all the changes that are occurring in anesthesia and moving towards system wide adoption of medication-safe practices and taking away bedside compounding, how do we get the frontline team members to come to the leadership to say, hey, this is where I'm having difficulty, or this is what we can do better in the process to overcome the production and the time pressures? Because in the end, in surgery and in anesthesia, the production pressures are real. Definitely, yeah. I loved what Yonika said on the importance of leadership as a cornerstone to promote this culture and the culture of reporting, the culture of safety in general. However, what you asked, David, is very important because here in accreditation, we use it as a system-wide tool to improve quality and patient safety. Now, we really focus on the fact that just having policies, procedures and recommendation, having them ready and then giving them to the frontline staff and asking them to deliver the service according to the policy, this will never work because we are here taking from them the ownership and taking them from them the active role and involvement in developing those practices. They are the frontline workers, they have the knowledge of the system, how it works, so we need to involve them, we need to have them on board with us to develop those practices and to make them fit the service provided. They need to feel that they are recognized for their efforts, they need to have an active voice in implementing those practices, and as Mike said, we need to incentivize reporting and to promote it and make it part of our structure. So a system-wide approach, it's not easy, it really needs commitment. The IHI framework for safe, effective and reliable healthcare is very simple yet it's very, it depicts the picture clearly that we have two arms, we have the culture, we have the learning system, and they are connected through leadership. So basically leadership is the linchpin of the whole framework. We need leadership commitment to promote the safety practices and we need to also involve frontline workers. The best approach we find from our experience is a multidisciplinary committee. The committee will be represented by pharmacists, clinical pharmacists, anesthesiologists, physicians, nurses, they need to be all involved in the governance of this initiative to improve anesthesia safety because we said it's not under one health provider, it is under a big umbrella and a cross-cutting across all departments in the hospital. So the committee needs to sit together and understand the safety issues, the holes in the system, how can we implement, how can we promote the adoption of the strategies, the safety strategies, and they can be very simple basic strategies or very challenging high bar to reach, but at least we need to take a step forward to improve the safety of the practice. Thank you Samar. Samar, Mike, what we're building is we're combining leadership with the front line. Yannicka, how do we take the human reaction to change? Because this is such a huge culture change in anesthesia and how do we get leaders to take this into account when when implementing these changes? Well, I think at least in my setting and I've heard in other settings they say that it's a natural human thing to be against change or be resistant to change that we want to do the same. I disagree, I think of course you can do that, but if you are able to make people understand why or make them to find out themselves why I change this. Then you have the motivation to do that, but if you are just told you have to do this and that of course you are resistant, I'm an individual person, I want to decide for myself and you are stupid anyway, but none of us want to do harm to patients. So if we understand and it's being explained to us or we find out by ourselves that this is smart to do, then we have the motivation, but we need to buy into that and understand why. Thank you, Yannicka, and that's why we're here today is exactly to do all of that because I as a front line team member have chosen this path to really build out anesthesia medication safety and exactly what you just brought home to understand why we are making these changes. Mike, when we look at mitigation variability and anesthesia safety, what are some things that we can do? To limit variability, I always try to figure out how do we develop automation, forcing functions, constraints if you will. So one initiative that some organizations are pursuing are pre-filled syringes and sometimes they're getting it from an outside manufacturer, they're getting it from a compounding facility or they're doing it in-house and if organizations can within their own teams of anesthesiologists, surgeons, pharmacists, etc. can come up with standardized concentrations for their area and standardized volumes. It makes it a lot easier and cleaner. This way you know what's expected for certain cases. You can prepare ahead of time and it also helps to limit any type of extraneous customized orders which sometimes have limited data or evidence behind them. Mike, we have a question from the audience that ties into our conversation right now. Are there any comparable benchmarks in this regard? I know from my as a front line we talked about overriding medications. Organizations are to track the percent and the number of overrides that are being done in areas like emergency room, critical care, and anesthesia which will create some benchmarks regarding that. Yeah, so in the United States there isn't a formal national benchmark but what has traditionally been used is looking at a 5% override rate and even that sometimes can be loosely defined. Some people will look at 5% override rate as overrides per total medications dispensed per automated dispensing cabinet or some people even look at it overrides per total medications administered and so if you look at that because of that inconsistency there isn't like a great benchmark out there what what I recommend for organizations to do and what I would what I believe a lot of other med safety officers across the country would recommend is that you not necessarily compare how you're doing versus compared or hospitals but rather how do you benchmark internally? So if you're in a 6-hom out of 6-hospital health care system it's very neat it's very good for us to look at what's our overall override rate and how does each patient care area, department or unit, compare to that overall system and the goal really is to figure out how do you kind of eliminate those even further? Are there certain medications that should not be overrideable? Are there certain units that are overriding a little bit heavier than others? So that's one of the downsides with benchmarks. I think the other point to note though is the question may have been asked are there benchmarks for medication errors specifically per hospital and technically there's some reported data in the literature we see it in PubMed we see it in academic journals however we have to recognize that those metrics those those benchmarks benchmarks measuring medication errors are those that actually are reported and detected. Think about how many times something goes wrong in anesthesia where we might have to give an antidote or we might have to reverse a patient and it's not necessarily reported within our own internal event reporting system and so those are some of the barriers to benchmarking overall at least when it comes to med safety so we always encourage internal benchmarking is always great and the goal just like as PSMF supports the goal should always be how do we get ourselves closer and closer to zero. Thank you Mike. Janneke how do we apply this internationally? Well I think just what we are doing right now is very important and also that we work on all the international organizations on those fields work with the WHO and other other international organizations that have a voice in this for instance the World Federation the WFSA which I have been the president we have published guidelines for the safe practice of the anesthesia together with the WHO it's easily found on if you search for it and those can be applied in all situations so that we have an agreed framework on what we want to do and then there are different levels of course but we have to work together internationally and nationally of course and locally for that matter. Thank you Janneke. Samar we tend to talk about key features of Team Workflow which is great to tie into a question that we have from the audience and that psychological safety and organizational reporting that won't be met with retaliation can you expand on that a little bit? Yeah sure. I just want to highlight the fact that we need to have a global perspective on this issue and we need to address the challenges that happens across the world not only in developed countries we need just to look at developing countries we need to look at low to middle income countries where the basics are not really established yet so we assume that we have an electronic decision support system we assume that we have barcode medication scanning we assume that we have smart infusion pumps with a software to detect errors but in reality a lot of facilities across the world they don't have that so basically do we abandon the notion of safe anesthesia care I think that's where we need to put our efforts we don't have to abandon our safe anesthesia strategy just because we don't have the technology or the resources because it is proven that taking simple strategies taking the steps that will lead us to the right path to prevent avoidable harms is applicable and can be done and basically even in areas where we have state of art hospitals we have all the technology we can still see overrides we can still see workarounds that will eventually lead to patient harm so that's why we need to rely on the system rather than the resources because the system itself if it's not built right if we don't have the culture of safety we will eventually abuse the resources that we have and we will eventually make errors that will lead to harm so the idea of culture the idea of addressing the safety issues we tend to think that anesthesia providers are superheroes they have the training the experience and they are competent enough to handle the workload but in reality it's not the case we have this full sense of safety we push the safety envelope just because we don't see any actual harm but the harm might be like Mike said might be undetected and the near misses is a very untapped treasure that we need to look into we need to learn from the near misses happen on a daily basis on an hourly basis in anesthesia care so if we disregard the near misses if we push them under the carpet and fail to learn from them I think it would be a huge mistake I love the quote that says to err as human to cover up is unforgivable and to fail to learn is unexcusable and that's the reality that we are living today so the culture in itself the safety culture regardless of the resources is very important what you said David about workflow is very important as well we address the situation that we might not have a dedicated OR pharmacist however by having governance from the pharmacy on the the whole medication management processes is very important so we need to monitor the practices of labeling a medication the waste management and disposal we need also to look into the the standardization and the storage of medication in the anesthesia room so if we look at the five as methodologies the simple act of sort set in order shine sustain standardize these simple processes can be really effective because an anesthesia provider rely very much on the structure of the medication trolley or tray so they reach for the medication because they are habitually just experienced to take it from here so if we standardize the storage area correctly if we implement strategies to prevent lookalike medication mix sound alike medication mix if we as Mike said limit the the variation in concentration of high alert medication like epinephrine and epinephrine if we can have them pre-prepared and ready to use at standardized concentration this will be very will have a very positive impact on the safety of medication so as we said we need to have a reliable process we need to make the process easier so we can do the right thing and difficult to make to make mistakes and difficult to do the wrong thing so we don't need to push the safety implement the safety envelope and we don't need to abandon the safety notion just because we don't have the resources thank you Samar Yannicka how do we tie all this into staff and workforce well yeah I was when Samar talked about developing countries I would say I live in one of the richest countries in the world and I hope it's still developing so we are all developing I hope but a big difference in in settings also in high income countries is the lack of workforce both as physicians nurses everything so and and then you come to to the problem how can you train people to do the right thing as Samar said if you if there are nobody to do that so this also ties in in order to give safe anesthesia and so on you need to be people to do that and also to look after and build all these institutional things that we are saying I just wanted to mention it as a topic because it's it's an issue in both high middle and low income countries Mike how does ARC work into this and staff that's a great question in the United States there's a group called the Agency for Healthcare Research and Quality and they really promote this ARC acronym ARCC it's for whenever a frontline individual a nurse maybe even a student identifies an unsafe condition or practice he or she can have the ability to ask a question and by asking that question that that individual that frontline practitioner can get better clarity if we feel for example that it's not addressed by that ask then that frontline clinician can then make a request and then if that doesn't work then they voice a concern and then the fourth C is said to use the chain of command so we do this right now especially in the pandemic and we should right we if we see patients and someone maybe it's a physician a co-nurse co- pharmacist comes into the room and they don't wash their hands if I'm in the room I might say hey Mike would you please wash your hands and if they don't wash their hands then I'd say please wash your hands and then if that doesn't work then I voice my concern and then if that concern still doesn't prompt that practitioner to wash their hands then I'm going to use the chain of command and I'm going to chat with that person's direct supervisor I think that regardless of where you are in the organization whether you are a student all the way up to a you know president ceo we all have a role in patient safety and using this arc acronym and using this escalation process gives everyone the tools and feels enabled to speak up for safety thank you mike we're kind of coming to a close I really want to say thank you to all the panelists mike samar and yannicka I'd like to move into opening up to the questions that we have from the audience one of the things that stands out from the audience comments and questions is the good catch and how that had a positive impact in one of the families samar closing that swiss cheese kind of let's talk about that a little bit for that family sorry I didn't cast the question david oh the good catch and how that had such a positive impact in in a positive culture in helping prevent patient arm for one of our audience's family members well I have to admit that I'm not very familiar of the program the good catch so maybe can help me mike or yannicka yeah mike yeah so a good catch program is such a neat way for frontline clinicians to be incentivized to speak up for safety and it allows them to intercept and doc to document the stuff that they intercept and intervene on at our organization we have these things called power of one awards and what they are there whenever an individual maybe a clinician or a non-clinician does something extraordinary and helps to prevent harm or does some sort of impactful intervention that improves quality uh what's so great about a good catch program in general you're able to foster a growth in reporting culture and if we recognize that reporting culture can sometimes have various challenges you know clinicians they're always seeing patients they're not always at their desk to uh you know type in these voluntary event reports we're hopefully able to overcome some of those barriers the other thing too I want to highlight is not only should a good catch program benefit frontline clinicians as they intervene and catch potential medication errors we need to figure out how do we incentivize patients and family members to get involved in their aspect of medical care as well too and so a lot of organizations as patients are being admitted um and then maybe a little bit it's probably a little bit different the pandemic and how sometimes there's sometimes a visitor restriction but in general we want to see how do we get patients and families involved so that way they themselves can speak up for safety I think that more and more organizations now have some sort of patient family advisory council and that is just such a great avenue for patient safety committees and patient safety leaders to work with so that way you get frontline experience as to what is it that our consumers our customers but are receiving as patients and families samar so you kind of want to add into that and on the aspect of incentivizing patients to speak up exactly um it comes actually in line of WHO WHO patient safety action plan that was released um for the years 2021 to 2030 the action plan has a full strategy on a patient engagement and patient family engagement and they really stress upon the fact that we need to engage the patient in their own um healthcare provision and we need to have a system for incident disclosure with the patient and their family so the the aspect of having incident reporting not just within the hospital and to the leadership and within the department but also how to disclose the incidents to the patient and their families and how to communicate the harms that has happened or where close to happen so it's very important as Mike said to have a patient advocate and to really um stand beside the patient and their journey and make them really aware of the the errors that happened and the harms that might occurred and have a really transparent conversation with them so this is a step that we need to take and not only reporting culture within the organization and for the sake of learning but also disclosure of incident to the patient and make them part of the journey because they are really the the first um one to be affected by the the error and the harm thank you samar yonica i think great opportunity to also add to this i would just like to say something because i know this is varying in different cultures some places uh you are also punished for openness so it's but i'm lucky to be in one where openness is uh is uh encouraged and i would just say what the australian open disclosure framework recommended in one of their earlier editions for open disclosure is that think about one day something went very very wrong imagine that this was about you or one of your family members what kind of discussion would you like to have with the healthcare providers afterwards this is such a good guiding principle if you put try to put yourself in the patients or relatives shoes and how would you like to have been met by the healthcare providers easy garden thank you yonica mike is anything you want to add here i just want to you know add you know i know we're talking about culture and then also different strategies that we can consider using one of the things i'd also add if if you aren't aware please consider taking a look at and ask me three approach it really allows the patients and family members to not just be more engaged with their with their healthcare but i also believe that it also allows them to catch potential errors so i think half the battle is how do we get patients and family members engaged thank you mike tomorrow panel let you close it out here before we turn it back over to dana thank you david thank you yonica and mike i really enjoyed the discussion and i learned a lot from you all i think i just want to end up on my favorite quote that the biggest room in the world is the room for improvement and i really believe in that and i believe that we can take small steps towards our main aim of zero harm to the patient and we can do that and it's achievable if we have the commitment and if we have the leadership support and if we have the safety culture so i believe in this opportunity to learn and to grow and to improve the anesthesia safety in general and medication management safety as a whole so thank you for the opportunity thank you thank you mike thank you samar thank you yonica dana i'll turn it back over to you here so you can close everything out today that's wonderful what a fabulous discussion this has been phenomenal thank you so much to all of our panelists who were here today thank you david for moderating this fabulous conversation one thing that i do want to make sure everybody is aware of is whenever we talk about resources on our webs on our webinars we always want to make sure that we link those on youtube and send them via email so and so so you can have access to the resources that our panelists spoke about again i just want to reinforce that this activity has been approved for one contact hour for nurses pharmacists and one category one credit for physicians through med star health respiratory therapists can also receive credit for this check with your state a lot of times respiratory therapists can can use nursing credit to apply for continuing education credit you'll receive a an email from med star health with instructions on on how to collect that that continuing education credit again for healthcare executives just log this into your aca account you'll receive a credit there certified professionals in patient safety will receive a certificate from the patient safety movement foundation and certified professionals in healthcare quality we will send your information to nyhq and they will document it there we are so blessed to be able to provide our educational content free of charge here at the patient safety movement we know that you know it's really really important that we all work together to strive for high reliability and we don't want costs to be a barrier so we would love to continue to provide our education free of charge but as a non-profit we really rely on donations to be able to do that so if you are interested in helping us keep our webinars free then you know please donate which can to support us you can see here at this at this link where you can go to directly donate there and we will have that available as a resource link as well so David I think we have just a few minutes left are there any other questions you'd like to address before we close out I think bringing back in the candor model is a good tie-in to this too one of the panelists like to kind of expand on that and how that relates to patient safety and patient family safety hey team I'm not an expert the candor model but it is a great approach from my understanding at least developing transparency and also disclosures I think from an IHI perspective oh I'm sorry go ahead Janneke no because we have been working at the patient safety movement foundation with the candor model for quite a bit and it includes open disclosure as we have said but also to take all the expenses from the family for further medical treatment so it's a whole very good system that should be shared all over AHRQ has a phenomenal blueprint for for candor that that is free to download and we've also done three webinars here at patient safety movement specifically about candor those are all available free of charge again on our youtube page so we can link those in in the resources section as well thank you Donna we have a little up two minutes left is there any closing comments any of the panelists would like to make here today go ahead Samar I just want to answer there's one question about the coat it is to err as human to cover up is unforgivable and to learn and to fail to learn is inexcusable it's I'm sorry I don't know the author but it's one of my favorite quotes Janneke you wanted to no I would just like to thank you all for this opportunity and to bring all stakeholders together which is what the patient safety safety movement foundation is doing because when we put all stakeholders together we can make real improvement and thank you for being allowed to be a part of that thank you well thank you to everybody again thank you David for moderating this fabulous webinar Mike, Janneke, Samar very very appreciative for all of your knowledge I know that the the audience has had some fabulous things to say about this so please everybody fill out your evaluations let us know what you thought of this session let us know what other education you might be interested in and we will see you again next month have a great day everybody thank you all thank you everyone