A patient was under the care of a resident and an attending anesthesiologist. The resident intended to draw up 0.2mL of 1mg/mL morphine from the Pyxis, but inadvertently removed a 10mg/mL morphine vial instead. The resident verbally confirmed “0.2 of morphine and 15 of fentanyl” to the anesthesiologist as the anesthesiologist administered the medication spinally. When the anesthesiologist subsequently wasted the residual narcotic, she noticed that the vial was 10 mg/mL instead of 1 mg/mL. The pharmacy was contacted and the patient was started on a naloxone drip with symptoms of sleepiness, nausea, and itching. The patient remained in postop to be closely monitored until symptoms resolved and naloxone was weaned off.

Medication errors in the OR are common and have considerable potential for harm. In fact, due to the fast-paced clinical environment, high acuity, and rapidly changing patient condition, medications are typically administered without prospective medication orders, double-checks by second providers, or electronic checks to warn of medication errors. As a result, medication errors are the most frequently cited error type in anesthesia. A medication error is defined as a failure to complete a required action in the medication use process, or the use of an incorrect plan or action to achieve a medication-related patient care aim (Crit Care Med 2005;33:1694-700; Anesthesiology 2016;124:25-34). Medication errors can occur anywhere along the medication use process and include errors of commission (e.g., wrong dose, wrong route) or errors of omission (e.g., missed antibiotic) (Anesthesiology 2016;124:25-34). Medication errors can lead to adverse medication events (AMEs), which are instances of patient harm or injury due to medication use, regardless of whether an error in the medication use process occurred (Anesthesiology 2016;124:25-34). Observational studies have shown that 4%-10% of perioperative medication administrations, or every second operation, involve a medication error (Anesthesiology 2016;124:25-34; BMJ 2011;343:d5543). About half of these lead to observed patient harm and the remainder have the potential for patient harm, with more than two-thirds of the harm classified as serious or life-threatening (Anesthesiology 2016;124:25-34). The cost of harm due to perioperative medication errors is $5.3 billion annually in the United States, and 95% of the errors are preventable (Anesthesiology 2016;124:25-34; J Patient Saf 2021;17:e758-e64; Anesth Analg June 2024).

Strategies to prevent medication errors typically fall into the following categories: standardization, pharmacy, institutional, and technology strategies. We will review some of these strategies, with a focus on those that could have prevented the error described in this case. Standardizing concentrations of medications, especially high-alert medications, within an institution or within a clinical care area (e.g., cardiac, pediatrics) is an effective medication error prevention strategy. Fewer concentration options can decrease provider uncertainty, reduce operational variations, and improve consistency, especially during transitions of care or situations involving multiple clinicians (asamonitor.pub/4cQrTTZ). In this case, one standard concentration of morphine may have eliminated the reported error altogether. The pharmacy can also implement strategies to prevent medication errors. For instance, storing regional anesthesia medications separately from standard medications that may contain preservatives serves to prevent inadvertent administration of a nonpreservative-free medication intrathecally, as may have occurred in this case. Additionally, providing prefilled syringes reduces the incidence of vial selection errors (Ann Emerg Med 2015;66:97-106). While prefilled syringes may have higher unit costs than vials, they reduce errors and waste while improving efficiency, aseptic conditions, and safety (Anesthesiology 2016;124:795-803; J Infus Nurs 2022;45:27-36).

Institutional culture and processes play important roles in preventing (or, conversely, facilitating) errors. For example, strong and effective communication within the anesthesia care team is essential for preventing medication errors. This is especially important when the clinician drawing up/preparing medications is not the same clinician administering the medications. Several lapses in communication occurred in this case. First, the resident did not include all relevant information when confirming the medication and dose with the anesthesiologist; verbal confirmation should include med name, dose, and concentration, with all applicable units. Second, the attending anesthesiologist did not use closed-loop communication. In closed-loop communication, the receiver paraphrases/repeats the message back to the transmitter, followed by confirmation or correction of the message by the transmitter (J Patient Saf 2023;19:93-8). If closed-loop communication of the required information was used in this case, the clinicians may have noticed that the concentration was incorrect. Effective communication can be facilitated by a robust culture of safety. In fact, several studies have shown strong links between a positive safety culture and positive perioperative outcomes (J Am Coll Surg 2019;229:175-83). Hospital and department leadership can foster a strong culture of safety by setting expectations that prioritize safety, establishing safety protocols, strengthening teamwork through training, and leading by example (asamonitor.pub/3xLzBju; Br J Anaesth 2017;118:32-43).

There are also technological innovations that can prevent medication errors such as the one described in this case. Specifically, clinical decision support tools that provide medication checks prior to medication administration have the potential to prevent 95% of intraoperative medication errors (Anesthesiology 2016;124:25-34; Anesth Analg June 2024). These tools provide auditory and visual feedback as well as algorithms that display alerts and other critical information (BMJ 2011;343:d5543; J Am Med Inform Assoc 2022;29:1416-24). In fact, professional organizations such as the Institute for Safe Medication Practice and the Anesthesia Patient Safety Foundation have recently released recommendations for the use of electronic point-of-care medication checks with clinical decision support in the OR (asamonitor.pub/4eLraVU; asamonitor.pub/3y7gGuD). While not yet widely adopted, there is evidence to support the efficacy of these tools in preventing medication errors and improving anesthesia workflows (BMJ 2011;343:d5543; J Am Med Inform Assoc 2022;29:1416-24).

In summary, important strategies to prevent medication errors include standardization, pharmacy, and institutional and technology tools. We have focused on the strategies that are most relevant to this case to provide examples of how they work to prevent medication errors in practice.

Who among us has not heard these dreaded words, or something similar? We do our best to avoid the problem, but still we occasionally fail, hand over emesis basins, and watch unfortunate patients heave into them. Perioperative nausea and vomiting (n/v) is both feared and loathed, and is a significant detractor to patient experience and anesthesia-related quality metrics. Further, in certain types of surgery, such as intracranial, facial plastics, and intranasal ENT procedures, the physical act of emesis poses a risk for incisional dehiscence(s), bleeding, and similar morbidity.

Let’s turn to our expert this month, Dr. T.J. Gan, a physician-scientist who is well versed in the epidemiology and treatment of all things nausea and vomiting-related. He will provide a refresher and some clinical guidance; hopefully, his experience can assist us in our quest to reduce “n/v” rates to as close to zero as possible.

Dr. Gan, thank you for joining us. Can you describe your current position and responsibilities?

I am currently Professor and Head of the Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine at University of Texas MD Anderson Cancer Center, a division with over 400 faculty, CRNAs, and staff.

Let’s dive right into this month’s topic. What are the most important patient risk factors for nausea and vomiting? Also, which surgical procedures are most closely associated with it?

The main risk factors for postoperative nausea and vomiting (PONV) include female gender, history of PONV and/or motion sickness, use of opioids, and nonsmoking status. Some surgical procedures, e.g., breast, laparoscopic, middle ear, strabismus repair, and neurosurgical are notably associated with higher risk for PONV.

Do we have a physiologic and/or molecular understanding of the genesis of PONV?

The act of vomiting is controlled by the vomiting center, which is located in the lateral reticular formation of the medulla. It receives input from the higher cortical centers, chemoreceptor trigger zone (CTZ), vestibular apparatus, cerebellum, and solitary tract nucleus. It also receives afferents from the optic, olfactory, vagal, glossopharyngeal, and trigeminal nerves, as well as from somatic structures such as the gastrointestinal tract, testis, pharynx, and heart. Efferent output from the vomiting center goes to the vagus, phrenic, and spinal nerves of the abdominal muscles. Receptors implicated in the etiology of nausea and vomiting include dopaminergic (D2), cholinergic (muscarinic), histaminergic (H1), serotonergic (5HT3), and neurokinin (NK-1). Currently available antiemetics act by blocking one or more of these five receptors.

What are the most efficacious treatments available in the United States?

Most approved antiemetics have similar efficacies, reducing the risk of PONV by about 25%. As PONV is multifactorial, a multimodal approach has been shown to improve efficacy. Adding the second antiemetic from a different class further reduces the incidence of PONV by another 25%. In the most recent consensus guidelines, we recommend administering at least two prophylactic antiemetics for those who have one or two risk factors and three to four for those above two risk factors (see algorithm). Commonly used antiemetics for adults are shown in Table 1, and for children are shown in Table 2.

For patients who develop PONV in the PACU or beyond discharge, prompt treatment is advised with an antiemetic that has not already been used.

Are there other useful treatments available worldwide that we might see here one day?

Recently, amisulpride (BARHEMSYS), a new dopamine antagonist, has been shown to be effective for prophylaxis (5 mg) and treatment (10 mg) of PONV. A new intravenous formulation of aprepitant (APONVIE) was recently approved by the FDA and can be injected as a bolus dose in the perioperative period. Oral aprepitant has been the only approved NK-1 receptor antagonist.

Can you describe any nonpharmacologic, yet efficacious, treatments?

Acupuncture is an effective nonpharmacologic technique for preventing PONV, with particular interest in the ‘P6 acupuncture point’ that lies 2 inches proximal to the wrist crease and between the tendons of palmaris longus and flexor carpi radialis. An updated Cochrane database review of over 50 random controlled trials found that P6 acupoint stimulation is well tolerated and is effective in the treatment of PONV, reducing the risks of nausea, vomiting, and the need for rescue antiemetics by similar magnitudes (RR 0.71, 95% CI 0.61-0.83; RR 0.70, 95% CI 0.59-0.83; RR 0.69, 95% CI 0.57-0.83, respectively).

What is a reasonable goal for rates of PONV?

Ideally zero, since, from the patient’s perspective, PONV is the most undesirable adverse event following surgery. It is one of the main reasons for patient dissatisfaction following anesthesia and surgery. With careful evaluation of risk factors and a comprehensive management strategy, a near zero incidence can be achieved.

Any comment on droperidol, a medication I used decades ago as a trainee, now not currently in widespread use due to the FDA’s black box warning?

In November 2001, the FDA issued a new black box warning on droperidol, which is the most serious warning for an FDA-approved drug. The FDA noted that its use has been associated with QTc segment prolongation and/or torsade de pointes, and, in some cases, fatal cardiac arrhythmias. Consequently, the FDA cautioned that droperidol should only be used when other “first-line” drugs fail. However, this decision has been challenged by many anesthesiologists. The manufacturer (Janssen-Cilag, Ltd.) decided to withdraw all formulations of droperidol. The rationale in halting production of the parenteral formulation of droperidol was solely economic. The manufacturer predicted that intravenous droperidol use would decline to such a low level following the new warning that it would be unprofitable to continue production of the parenteral formulation. Nevertheless, recently there has been some availability of droperidol on the market, and many practitioners use a smaller dose, 0.625 mg-1.25 mg.

What is your prophylactic approach to PONV?

In patients with one or two risk factors for PONV, I routinely administer dexamethasone and ondansetron as prophylactic agents. For patients with three or four risk factors, I will add either aprepitant or transdermal scopolamine. In addition, I would administer TIVA with propofol as the main anesthetic, avoiding volatile agents and nitrous oxide and use sugammadex for neuromuscular reversal instead of neostigmine. I will also minimize the use of opioids, as they are highly emetogenic, by using a multimodal analgesic regimen or regional anesthesia. Figure 1 represents a PONV management strategy algorithm for adults.

You mentioned scopolamine. Can you comment on its efficacy in patients lacking a history of motion sickness and its effects in geriatric populations?

Scopolamine has similar efficacy as the other antiemetics. It is commonly used for motion sickness but is also independently effective in the prevention of PONV. Due to the transdermal delivery, plasma concentration peaks at around four hours after administration. Hence, it should be applied in the preoperative phase. However, it is associated with a number of anticholinergic side effects, with dry mouth, double vision, and dizziness being the most prominent, especially in the elderly population. Unfortunately, the patch formulation does not allow for dose adjustment. I instruct patients to remove the patch when they are not able to tolerate the side effects.

What to do when “we’ve tried everything” and the PACU nurse calls about a patient who is still nauseated/vomiting?

If patients develop PONV in the PACU, I administer amisulpride (dopamine antagonist), diphendydramine (histamine antagonist), or promethazine (dopamine/muscarinic/histamine antagonists). Dosing of propofol in small (20 mg) boluses has been shown to be effective in quickly alleviating the severe nausea sensation. I.V. aprepitant is recommended for those who still have vomiting.

Any parting words of wisdom for our readers?

You can make a difference! PONV is an unpleasant and unfortunately common side effect of anesthesia and surgery. It is the main driver for patient dissatisfaction. With careful evaluation and planning, and appropriate use of prophylactic pharmacologic and nonpharmacologic options, patients do not have to experience this, and they will be forever grateful if you are the anesthesiologist who makes that difference.

Other than relationships with family and friends, the relationship to one’s employer may be one of the most important in a person’s life. When you spend 40, 50, 60, or more hours a week in the service of an employer, the relationship can affect your physical and emotional health in a myriad of ways. With all of the rapid changes taking place in health care (regulatory, economic, clinical, etc.) the employer-employee dynamic changes continuously. This month, we underscore some of those important changes and how they impact the practice of anesthesiology.

Dr. Polce discusses the critical role that capital plays in his group’s practice. Backed by a large private equity (PE) firm, he reviews how his employer’s partnership with PE allowed his group to not only survive, but to thrive in a perilous health care environment.

Attorney and practice management expert Judith Semo reviews a critically important issue that is often overlooked by anesthesiologists – mandatory arbitration clauses. Though physicians often focus on compensation and duty hours when reviewing employment contracts, mandatory arbitration can have far-reaching consequences for one’s employment and relationship with their employer.

Drs. Beta, Ural, and Rafique discuss staffing models and strategies for anesthesiology. When an employer sets a group’s staffing, it affects not only one’s duty hours and lifestyle, but also job satisfaction. Anesthesiologists practice in a large range of staffing models, from MD-only to large care teams, and this fact is a crucial determination when a prospective employee interviews for a job, or chooses to continue employment.

Drs. Ibekwe and Gupta dive into quality metrics – a critical issue that affects patient care. Quality metrics are frequently highlighted by administrators and used as a component of compensation, but do they really improve value? How are these indicators used by an employer to determine employee efficacy at the patient bedside? What does the future hold for anesthesiologists seeking employment? The only certainty, it seems, is that change will continue.

One such change, occurring with more frequency in many parts of the country, includes a shift to hospital-based work or employment with a large health care system. Historically, physician practice was synonymous with being an entrepreneur. Often, the image of doctors in society was that of the solo practitioner or the owner-partner within a group of health care professionals, working long hours, but directly reaping financial benefit from their extraordinary efforts. Increasingly, however, physicians are either transitioning to employee models of practice from partnership or spending their entire career as employed practitioners. These non-owner employees may work for physician-owned groups, PE-backed corporations, or hospitals and health care systems. It is this last trend – to hospital-based or health care system-based employment that we will discuss further.

According to an analysis by the American Medical Association (AMA), between 2012 and 2022, the number of self-employed physicians fell by 9%, and nearly half (49.7%) were employed by another entity (asamonitor.pub/3VCQxk9). During that same 10-year period, the share of physicians working in private practice dropped from 60.1% to 46.7%. In the same study, the share of physicians employed by, or contracted directly with, a hospital increased from 5.6% to 9.6%. Physicians working in a hospital-owned practice increased from 23.4% to 31.3%.

There are a variety of reasons a physician would seek direct employment by a hospital. Potentially of more interest, however, is why a practice owner would pursue acquisition by a hospital, especially given the likelihood of a reduced (or absent) payout. This is especially true when compared to a potential PE-backed acquisition. The AMA 2022 Physician Practice Benchmark Survey assessed the underlying motivations of physicians who had switched to hospital employment. Of the survey respondents, 79.5% cited negotiating ability for higher payments as an important or very important reason for their decision to be acquired by a hospital (asamonitor.pub/3VCQxk9; asamonitor.pub/3VEXzEP). Further, 69% cited access to costly resources and 71.4% cited regulatory and administrative requirements as important or very important factors.

I recently had the privilege of discussing hospital-based employment for anesthesiologists with several physicians who have been through the transition from private or corporate-owned practice. David Ryu, DO, is Medical Director for Anesthesiology at Holy Name Medical Center in Teaneck, New Jersey. In 2018-2019, his hospital transitioned perioperative services from TeamHealth to hospital employment, and he and many of his colleagues remained at Holy Name, citing their dedication to the hospital and community as their primary consideration. He states that his “mission is to take care of the patients” and believes that this employment construct enables him and his colleagues to be more involved in the hospital ecosystem. Whereas, under his prior employer, decision-making may have been slowed by layers of bureaucracy, he states that direct employment allows his department to be more “nimble.” For example, he can now pick up the phone and speak directly to the chief medical officer and is able to quickly streamline decisions related to quality, patient safety, and clinical or financial considerations.

“It’s the way things are going,” Dr. Ryu continued, referring to hospital-based employment. He went on to explain that the private practice model suffered from declining reimbursement and regulatory or administrative pressures. That likely led to the influx of PE investment in the health care industry. Groups and clinicians then benefited from the ability to outsource financial and administrative responsibilities, focusing instead on patient care. Further financial strain due to declining reimbursement and ongoing staffing shortages, however, likely led to an increased need for facility stipends or reduction of services. These factors often lead to conditions that prompt hospitals and health care facilities to seek out direct employment models.

Jonathan Bauman, MD, is the Medical Director of Anesthesiology for Northwell Health in New York state, serving dozens of hospitals and ambulatory surgical sites. His private practice was directly acquired by the health care system, and he now oversees about 700 anesthesiologists and nurse anesthetists. In addition to leading the integration of his former partners into the Northwell system, he has worked to transition many of Northwell’s sites from other practice modalities to fellow hospital employees. He cites the success of his system’s anesthesia service line to the belief that this model allows the anesthesiologist to “focus on the patient.” He believes that Northwell’s model continues to attract new employees because “the security is there.” When he and his partners considered the initial offer to join Northwell as hospital employees, their single biggest consideration was long-term planning. They found that those interests were well-aligned with the hospital, given their mutual focus on both patient care and quality of services. Despite leading a large number of health care providers at countless facilities throughout New York, Dr. Bauman has been given great autonomy to direct clinical care, stating that Northwell “is not looking to change our clinical practice.”

Is hospital employment a passing fad, or is it the new normal for anesthesiology? When the article “Understanding the Physician Employment ‘Movement’” by Bonnie Darves was published by the New England Journal of Medicine in 2014, long-term economic effects of health reform and declining reimbursement were cited as primary reasons driving physician employment models (asamonitor.pub/45Y8j6h). Work as an independent practitioner or as a partner in a private practice often requires the desire to run a business, with its associated responsibilities and stressors. Those physicians who choose employment can focus on their clinical practice instead of financial and regulatory burdens. Consequently, the author states that hospitals and health care systems also seek direct employment to ensure improved alignment for both clinical and financial interests between providers and facilities. This is especially true as efforts increase to improve health outcomes and cut costs as systems form or join accountable care organizations.

For those physicians considering this career path, it is important to consider performance expectations by their prospective employer. This includes successful identification of performance and productivity metrics in their contract. When a practitioner chooses a newly formed hospital-based group, it is also especially important to consider the goals, vision, philosophy, and plans of the organization. Though it remains to be seen if hospital employment will be an ongoing trend, it is clear that this employer-employee relationship may offer anesthesiologists unique opportunities for future consideration.

Which of the following adjunct medications will MOST likely increase seizure duration when used during electroconvulsive therapy?

• (A) Lidocaine
• (B) Dexmedetomidine
• (C) Caffeine

Electroconvulsive therapy (ECT) for depression is considered effective if a seizure lasts 15 to 25 seconds after delivery of the shock. Anesthetic management for ECT usually consists of an intravenous injection of a hypnotic drug followed by a paralytic drug. The hypnotic agent is administered to ensure amnesia prior to pharmacological paralysis and ECT. The paralytic medication (often succinylcholine or rocuronium) prevents injury to the patient during ECT and the resulting seizure. The seizure is observed and measured using two methods. Direct recording of the electroencephalogram is done with electrodes positioned on the head. Observation of the motor seizure is accomplished by isolating a limb (usually the foot) from the effects of the paralytic drug using a proximal tourniquet. The time of tonic-clonic contractions of the foot is then measured.

Methohexital and propofol are commonly used hypnotic agents that also have some anticonvulsant effect. Propofol’s anticonvulsant properties lead to a shorter seizure duration. The addition of intravenous lidocaine prior to the injection of propofol, ostensibly to prevent propofol-induced pain on injection, may further decrease seizure duration.

Other adjunctive medications have been investigated that reduce the amount of hypnotic medication needed to ensure amnesia. For instance, dexmedetomidine added to a hypnotic has no direct effect on seizure duration but may reduce increases in blood pressure and heart rate that occur as a result of ECT.

Adjuncts, including glycopyrrolate, labetalol, and esmolol, are used to treat the parasympathetic and sympathetic responses to ECT. Ondansetron may be administered to prevent nausea, and nonsteroidal anti-inflammatory agents are often given to help with muscle pain. Caffeine has been shown to enhance seizure quality and duration when used as an adjunct to ECT.

Answer: C