Adverse events in radiation oncology: A case series from Wake Up Safe, the pediatric quality improvement initiative

This is a review of data from a voluntary, multicentre registry of paediatric anaesthetic adverse events (USA), looking specifically at remote anaesthesia in radiation oncology. It was looking for patterns of Serious Adverse Events (SAEs) in the hope of producing recommendations for anaesthetic management. There were 6 reported SAEs of 48,578 anaesthetics in radiation oncology locations with an incidence of about 1/8,000, although this is probably an overestimate of incidence because of coding anomalies.

There were 3 cases involving anaesthetic error with incorrect pump programming, 1 case of laryngospasm with delayed detection (no monitoring in transit), 1 case of laryngospasm probably secondary to copious secretions under a simulation mask, and a case of bronchospasm with unintended extubation and cardiac arrest with late recognition exacerbated by a head frame. In all but one the main cause was practitioner error with some environmental contribution. The recommendations include steps to prevent medication errors (two provider checks, intelligent pumps, bar-coding), cameras to visualise all monitors, pumps, machines and airways, and continuous monitoring of oxygenation and ventilation (including during transport). Any impediment to airway management should be removed ASAP.

Take Home Message:

I can’t disagree with the recommendations. Nothing surprising there – do the basics well. In the 5 cases where the cause was primarily the practitioner, they were a trainee or a nurse practitioner but no comment was made about experience. As acknowledged the figures are a little rubbery but useful, and greater understanding of the events is hampered by limited, retrospective information.

Reviewed by:  Dr David Barker