Among the various meetings I attend, as a senior-level hospital center administrator, is the “Executive Safety Meeting”. At this meeting, we discuss issues of concern under our roof, as well as planned preventive measures and alerts we’ve received from outside organizations and agencies.
Recently, we received a “Sentinel Event Alert” from the Joint Commission, an oversight organization I’ve mentioned in previous posts. Sentinel Events are major errors and other events causing what are euphemistically referred to as “negative patient outcomes.”
This particular alert, drawn from real events at hospitals around the country, warns of problems with “anesthesia awareness” and suggests some procedures to avoid this happening.
What is anesthesia awareness? (N.B.: This is where the squeamish among you may wish to stop reading. In fact, I almost wish I hadn’t heard of this!)
Anesthesia awareness is something that can happen when someone is undergoing surgery or some other procedure and has been given anesthesia to put them under and a drug to paralyze much of their musculature, so that the procedure may be completed.
The “awareness” part comes when the amount of anesthesia turns out to be insufficient, so that the patient becomes aware of what’s going on while the surgery is still going on!!! Unfortunately, the drug causing muscular paralysis is still working, so they can’t do anything about this, like start screaming. I don’t have much to add, except that the very thought of this is horrifying.
I’m glad it hasn’t happened under our roof, but the fact that it apparently has happened elsewhere, enough times for a national alert to go out, is sufficient to scare the bejeezus out of me!
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