Dental anesthesia safety: Say something if you see something

At the recent CDA Presents The Art and Science of Dentistry convention in San Francisco, Steve Yun, MD, provided an enlightening and practical examination of dental anesthesia and patient safety in his course Myths and Errors in Dental Anesthesia: Avoiding Office Disasters (see page 6 of the Program). In this interview, Yun shares his top tips for enhancing patient safety during dental anesthesia.

Q: Dr. Yun, please tell us a little bit about yourself and why the subject of anesthesia safety is so important to you.
A: I am a board-certified M.D. anesthesiologist who specializes in dental office anesthesia. I am an anesthesia inspector for the Dental Board of California and a safety inspector for ambulatory surgery centers. I am also a volunteer instructor at the Loma Linda University School of Dentistry.

My passion for patient safety comes from having reviewed hundreds of medical and dental malpractice cases as an expert witness. I have analyzed numerous anesthesia disasters that tragically could have been prevented if there had been a greater emphasis on patient safety. Finally, as a regional representative for the Patient Safety Movement Foundation, it is my personal and professional mission to do anything I can to help improve patient safety.

Q: Why is anesthesia such an important tool for dentistry?
A: Dentistry has played a strong role in the history and development of anesthesia. As a physician anesthesiologist, I am indebted to the dental pioneers in our field. Anesthesia continues to play an important role in dental practices today as we all strive to provide humane, compassionate treatment to our patients. In addition, the number of patients who need anesthesia seems to be on the rise, such as patients with dental phobias and the inability to cooperate due, for example, to severe autism or developmental delay.

Physicians are only now starting to appreciate the huge impact oral hygiene has on our overall health. Humane, compassionate and safe anesthesia in the dental office allows us to take care of patients who otherwise would not be able to tolerate dental procedures, thereby improving not only their dental health but also their long-term overall health.

Q: What elements of your anesthesia practice have grown in importance over the years? 
A: Many technological changes and advances have occurred in the field of anesthesia, but perhaps the biggest change in my anesthesia practice over the years has been cultural. There is now an emphasis on the team model, meaning that as an anesthesiologist I must recruit and activate each member of the treatment team to take an active role in patient safety. Dentists, dental assistants and the front-office staff must be recognized as important and valuable members of the care team when it comes to anesthesia patient safety.

Another important change is the introduction of the pre-procedure checklist and professional guidelines. Twenty years ago when I was in anesthesia residency at UCLA Medical Center, we did not use checklists prior to the procedure. Our professional societies also did not publish many practice guidelines. The culture of our training and practice at the time was that the physician was an independent practitioner who used his or her own judgment to customize the practice as they felt appropriate. The culture now is toward more standardization and accountability.

Q: What steps, exercises or briefings do you do with your office team prior to each anesthesia procedure?
A: I travel to dental offices all over the state to provide anesthesia to patients who require sedation to receive dental services. Whenever I come into an office, I introduce myself to each member of the team. Saying hello and asking, “What is your name and role?” is very important. Simple introductions help foster the “activation concept,” where team members feel empowered to speak up in case they see something wrong with the anesthesia process. Indeed, the first and most important rule I tell the office staff is to “Say something if you see something!” As the captain of the anesthesia team, my job is to create an environment where the office staff can feel comfortable telling me that something may be wrong. In turn, I make the promise to respect their input and to never discount their role as patient safety advocates.

In addition, I will review basic emergency procedures with the office, check backup emergency equipment and complete my pre-anesthesia checklist before every procedure.

The pre-anesthesia checklist is especially important. I personally use a checklist that I downloaded from the website of the American Dental Society of Anesthesiology. I have customized the list to fit more closely with my protocol and I encourage others to do the same. This should be a tool that is relevant and useful for each practitioner.

Thanks to the work of Harvard surgeon Dr. Atul Gawande (author of “The Checklist Manifesto: How to Get Things Right,” a book that I strongly recommend everyone read), we know that checklists can save lives. As human beings, we will inevitably make a mistake. Checklists are one way we can help protect the patient from human error.

Q: Do you direct patients, parents or guardians to any resources prior to performing a procedure?
A: I refer my patients to my website and give them my anesthesia forms well in advance of the procedure. Parents of young children especially need time to process the information and understand the risks and benefits of anesthesia. If at all possible, I try to avoid giving patients information at the last minute. I also make it a practice to give patients my personal cell phone number and email so that they can contact me anytime if they have questions prior to their procedure. My advice to dental offices is to patiently and repeatedly explain the risks, benefits and alternative types of anesthesia. Patients need time to process this information.

For more general information on dental anesthesia, some very good resources are available on the websites of the American Dental Society of Anesthesiology, the American Society of Dentist Anesthesiologists and the American Academy of Pediatric Dentistry.

Q: What in your view are the key things a dentist who provides sedation services can do to increase patient safety?
A: 1. Resist taking shortcuts; always put patient safety above other considerations. As health care professionals, we have an ethical responsibility to go above and beyond when it comes to protecting our patients and must take active steps to create a culture of safety in our offices. (A useful survey to gauge your office's safety culture is available through the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality.)

2. When a patient’s vital signs signal the patient is in distress and you begin emergency rescue procedures, call 911 first. Waiting too long to call 911 is one of the most common mistakes I see in dental anesthesia tragedies. I often say that the worst result of taking this action is that you will have several very capable emergency personnel hanging around to provide additional support should that be needed.

3. Follow the anesthesia and sedation guidelines as promulgated by our national professional associations.

4. Practice, practice and practice emergency protocols for medical emergencies. In a crisis situation, our natural instinct is to “freeze,” and our skills, cognitive reasoning and judgment suffer. The best way to counteract this is to continuously overpractice emergency protocols. Keep a visual cognitive aid, such as a handbook, with your emergency equipment to help remind you of the basic steps in the management of medical emergencies. A handbook I personally use is published by the Stanford Department of Anesthesiology and can be downloaded free of cost.

5. Be prepared for failure and respect Murphy's law. For example, equipment will eventually malfunction or get old and break down. Most equipment has a recommended schedule for maintenance and, in many cases, such as with an AED, there are regulatory requirements to document maintenance. In particular, Ambu Bag and masks need to be checked. Too many times I have inspected offices where the emergency equipment was broken, e.g., a cracked plastic ring on the Ambu Bag or it was in a unusable state. Instead of blindly assuming, “That will never happen in our office," ask instead, “How could this happen to us and how can we prevent this?” Undertake a brutally honest survey of your office and take steps to correct hidden flaws or latent errors before a disaster occurs. What’s more, keep a log of inspection and maintenance for all emergency equipment, including your emergency drug kit.

Q: What would you want dental professionals to know about this subject that you have not yet mentioned?
A: Above all else, maintain a healthy respect and even fear of the anesthesia process. For the vast majority of our patients, the anesthesia process is smooth and seemingly easy. But complacency and overconfidence can quickly produce fatal, disastrous results. Thinking “I have always done it this way and I have never had a problem” is a flawed perspective that will lead to a tragically predictable negative outcome.

Dr. Yun can be reached by email.

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