The saying, "to err is human",¹ applies to all of us; however, because patient's lives are in our hands during anesthesia, mistakes can lead to significant morbidity and sometimes mortality especially under stressful conditions. Anesthesia is required for most surgical procedures and many diagnostic procedures including endoscopy, and imaging (e.g., CT and MRI). Anesthesia is a temporary state of unconsciousness and requires careful assessment of the patient, choosing the correct drugs and doses, ensuring correct functioning of the anesthetic machine and monitors, and assessment of anesthetic depth and vital signs. The anesthetist must also predict critical events and be prepared to intervene. Anesthesia is a complex science and as stress, fatigue and complexity of a procedure increase so is the likelihood of errors. In addition, a large number of personnel may be involved in one patient's care and communication between all team members is essential for a good outcome. The anesthetic mortality rate in veterinary anesthesia is much higher than in human medicine and specific risk factors have been identified including the patient's physical status and age;¹ however, human error still plays a significant role in morbidity and mortality.

Atul Gawande (The Checklist Manifesto; How to Get It Right) makes the case that checklists help us manage the complexity of anesthesia and surgery; he states that the problem is "making sure we apply the knowledge we have consistently and correctly." He studied professions where checklists have been successful in avoiding mistakes and saving lives, including the aviation and skyscraper construction industries. The introduction of checklists in human medicine has had a dramatic effect; in surgery patients they have decrease mortality by up to 50%.

The veterinary profession is now following these recommendations by implementing anesthesia and surgery checklists.^3,4 A Patient Safety Incident is defined as "any deviation from usual medical care causing injury to the patient or posing a risk or harm to the patient.⁵ Hofmeister and colleagues recorded the most common anesthetic incidents in their hospital over an 11-month period, then developed interventions to address these and determined their effectiveness.

Adverse incidents recorded included closed adjustable pressure limiting valves, esophageal intubation and medication errors. The intervention for medication errors that was introduced required the person that was to administer the drug to say out loud, the name of the drug, the patient's name and the route of administration. The impact of their patient safety interventions was significant, and resulted in more than a 50% decrease in errors. It should be mentioned that for checklists to be successful everyone in the team must "buy in" to the concept. There may initially be resistance as some team members may think they are above making mistakes and they may feel that their ability to approach things "their way" or their autonomy and clinical judgement is being challenged. Another concern that is often raised is that check lists will slow things down leading to unnecessary delays; however, there is strong evidence that checklists improve efficiency.

The Association of Veterinary Anaesthetists (AVA) have developed anesthetic checklists. The objectives of the AVA's recommended procedures and checklists are:

1.  To outline an appropriate manner and order in which to perform key procedures in the anesthetic process

2.  To reinforce recognized safe practices by ensuring critical safety steps are performed before moving between key points in the anesthetic process

3.  To improve teamwork and communication during the anesthetic process

The anesthetic process can be divided into three phases with checklists designed to be conducted between these phases:

1.  Immediately prior to induction of anesthesia

2.  Immediately prior to the procedure beginning (e.g., before the first surgical incision is made)

3.  Immediately prior to recovering the patient

At these 3 times, the team should confirm that each check has been performed and that critical safety and relevant patient information has been communicated between team members. All check points should be completed before the next phase is started. The act of performing each of these steps is called a "time out". A checklist should be short and easy to read and complete; it should not take more than 1 to 2 minutes to complete; most can be done in less than a minute. One person should be designated to initiate the checklist process and from experience this is best done by a nurse or technician.

For anesthesia staff important tasks include:

1.  Checking the anesthesia machine: is there an oxygen source, is the correct breathing circuit in place, is the vaporizer filled, has the machine been leak checked, is the adjustable pressure limiting valve open?

2.  Are monitors available and working?

3.  Has the patient been correctly identified (e.g., with an identity band), has the procedure been confirmed, and for many procedures has the correct site (left or right) been confirmed?

4.  Are all the correct drugs and doses ready for use and labelled, have emergency drugs been calculated and are they available?

5.  Is all the appropriate equipment for airway management ready?

6.  What critical events are anticipated? For example, if blood loss is anticipated has the patient been blood typed or cross matched and is the blood on hand? Have these risks been communicated to the whole team?

7.  Who is responsible for the patient's anesthetic care?

8.  During the recovery period, where will the patient recover, has a post-anesthetic plan been drawn up, and what is the analgesic plan?

Ready to use checklists can be downloaded and used (see Resources), but these can also be tailored to any clinic's specific needs or to target an identified area of weakness. Once a checklist has been initiated it is important to get feedback and test it by tracking critical events. Veterinarians and technicians are strongly encouraged to use checklists as they can decrease stress in the team, improve communication, improve team work, save lives and result in greater job satisfaction.

Resources

 Gawande A. The Checklist Manifesto; How to Get Things Right. Metropolitan Books: New York, NY: Henry Hold & Company.

 Mankin K. www.cliniciansbrief.com/article/checklists-answer-avoiding-mistakes. 2016.

 Association of Veterinary Anaesthetists. Anaesthetic safety checklist. http://alfaxan.co.uk/documents/resources/downloads/UK/AVA_Anaesthetic_ Safety_Checklist_FINAL_UK_WEB_(1).pdf.

 Association of Veterinary Anaesthetists Anaesthetic Safety Checklist Manual Implementation Booklet: www.ava.eu.com/wp-content/uploads/2015/11/AVA-Checklist-Booklet- FINAL-Web-copy.pdf.

References

1.  To err is human; building a safer health system. Institute of Medicine. 1999.

2.  Brodbelt D. Perioperative mortality in small animal anaesthesia. Vet J. 2009;182(2):152–161.

3.  Armitage-Chan EA. Human factors, non-technical skills, professionalism and flight safety: their roles in improving patient outcome. Vet Anaesth Analg. 2014;41(3):221–223.

4.  Hofmeister EH, Quandt J, Braun C, Shepard M. Development, implementation and impact of simple patient safety interventions in a university teaching hospital. Vet Anaesth Analg. 2014;41(3):243–248.

5.  Haller G, Laroche T, Clergue F. Morbidity in anaesthesia: today and tomorrow. Best Pract Res Clin Anaesthesiol. 2011;25(2):123–132.