Case Studies of Near Misses in Clinical Anesthesia

Abstract

Case Studies of Near Misses in Clinical Anesthesia J. G. Brock-Utne Springer , July , 2011 , ISBN 978-1-4419-1178-0 , 236 pp., Price £35.99 Learning from adverse anaesthetic events, whether from books, journals, meetings or coffee-room conversations with colleagues, is an important method of improving the care we provide. Certain potentially disastrous events happen rarely; consequently they may not have been considered and a plan or solution may not be immediately to hand. Frequently, on hearing of a near miss, my initial relief that it didn’t happen to me is replaced by confidence that I’d be better prepared if it did. It is vital we learn from others’ mistakes and experiences, and this book offers a rich source of such material. With over 40 years’ clinical practice in Scandinavia, South Africa and the US, John Brock-Utne has collected 80 short case studies of near misses, all based on real cases. Though an eclectic mix, many are relevant to everyday anaesthetic practice: lost teeth; pulmonary aspiration; failure to flush intravenous lines; and difficulties inserting nasogastric tubes. All are events that have occurred in my workplace within the last few years. Through these 80 cases Brock-Utne has produced a scattershot of ‘top tips’ for anaesthesia. The typical format is a page detailing a scenario with enough information to diagnose and treat a possible anaesthetic catastrophe. Most start with a general statement, e.g.: “Today you are assigned to anesthetize a 52-year-old man with myasthenia gravis for a coiling of his cerebral aneurysm”. Others are more specific, my particular favourite being: “You are a retired anesthesiologist (72” and 250 lb) living in Maui, Hawaii”. There follows a question, and on the next page a solution is offered; finally a summary of the salient points is made in a recommendation. Each solution has a few references, many originating from the author’s department. Whilst most cases are set in the operating theatre, there is a diverse range. A breadth of anaesthetic practice is covered, from cardiac and neonatal surgery to minor day surgery. A small number of cases deal with intensive care, obstetric anaesthesia and the pre-operative assessment clinic. All but a few are set in developed world hospitals. Many of the cases deal with a single issue; a few concern interactions with other health care professionals, particularly surgeons, patients and their relatives. This is an underdeveloped aspect of the book; the place of non-clinical and human factors in near misses is touched on but could have been explored more fully. The cases are easy to read, although the text would have benefited from closer proof-reading. The lack of organisation is frustrating; it is often difficult to know the crux of a case from the title alone, there is no grouping of cases, and the index is poor. Furthermore the cases’ learning points are often underutilised. Only two cases have any figures, diagrams or data; too often we are simply told the interpretation of any investigations. The solutions offered are very pragmatic and whilst occasionally I did not fully agree with them or had an alternative, this does not detract from their usefulness. The solutions are often what was actually done, as opposed to an ideal answer; there is rarely one correct way to deal with a problem and the cases in this book can form the basis for discussion of alternative management plans. In summary, Brock-Utne is obviously a knowledgeable and passionate teacher and whatever the stage of your anaesthetic career you are bound pick up some previously unknown pearl of wisdom from this book. The book’s contents are concise, interesting and of practical use; however, accessing them should be easier.