One of the best safety strategies in anesthesia is the anticipation and prevention of complications and errors at every step of preparation. An intact intravenous drug delivery system is essential for almost every anesthetic plan. In this article, we will specifically discuss the intravenous drug delivery system, focusing on its vulnerabilities, strategies for preparation against potential complications, and error prevention. We visualize this concept as an educational endeavor and as a tool to enhance quality assurance and risk mitigation in anesthesia practice.
There has been considerable research on the reliability, safety, and vulnerabilities of drug delivery systems in anesthesia. However, the idea of “single points of vulnerability (SPOV)” may not be widely conceptualized within routine anesthesia practice. SPOV may be defined as “where any one defect can jeopardize the system and may lead to complete failure of the system.” In anesthesia practice, each maneuver performed by every team member can have consequences and can lead to significant vulnerability or, less commonly, complete failure of the anesthetic plan.
The concept of SPOV is inspired by the “single point of failure (SPOF),” which is utilized in many industrial and technological utilities such as space travel, the airline industry, and manufacturing. This concept aims to identify when one single step can lead to the complete failure of the whole system. A relevant example of the use of this term was during the construction of the James Webb telescope. This project took two decades, $10 billion, and 20,000 people to complete. During the construction of the telescope, the team identified 344 single points of failure during the unfolding of the telescope in space. The result was a successful launch and perfect deployment of the telescope despite the complexity of the project and the high stakes involved.
In the existing medical literature, studies on equipment malfunction, human error, and system design flaws shed light on factors affecting patient safety. Research often extends into broader areas of patient safety, medical device innovation, and clinical best practices in anesthesia. However, the specific focus on SPOV within anesthesia practice remains niche. Continuous technological advancements and the critical nature of anesthesia in patient care motivate ongoing investigation into improving these systems’ reliability and safety. By addressing SPOV, we aim to underscore the critical aspects of patient safety, the reliability of medical equipment, and the continuous improvement of anesthesia practices. As we set up an IV infusion system for intraoperative use, we must be cognizant of every point of vulnerability that can affect the reliable use of any medication. This can include the expiration date of the drug, the right dose, the right patient, the right concentration, the integrity of the infusion tubing, the battery status/electrical connection of the pump, the distance and integrity of the connection of the medication tubing from the line carrying the fluids and medications, and the concurrent use of other medication, to name a few. Malfunction of any of these vulnerable points can add unpredictability and confusion at a critical time during the intraoperative course. Such endeavors are crucial given the complexity and high stakes of surgical procedures, where exploring these issues will not only contribute to enhancing health are quality and informing best practices among clinicians but also lead to mitigating risks and fostering further innovation in medical technology.
Understanding IV drug delivery systems in anesthesia
In order to explain the concept of SPOV, one area of concern we can examine is the IV drug delivery system as our primary system. This setup includes various styles of IV lines, fluid warmers, three-way stopcocks/manifolds, drug infusion pumps, saline locks, secondary infusion bags for antibiotics and vasopressors, and angiocaths in situ, among others. Such systems are known to every anesthesia provider. In this article, we implore readers to consider this system from a fresh perspective.
Consequences of system failures
As shown in Figure 1, various factors can lead to a vulnerable or failed anesthetic plan. There are many different mechanisms by which the anesthetic system can fail. These factors are listed in Table 1. Damage or kinks to the tubing, as well as disconnection or infiltration of the IV line, can lead to the loss or unclarity of the drugs or fluid reaching the patient, leading to an inability to resuscitate a critically ill or vulnerable patient. Contamination of the ports can directly lead to infections of the patient’s bloodstream. Pump failures, loose connections, and disconnection of the drug pump can also lead to inadequate, inaccurate, or failure of drug delivery to the patient. Compromised drug administration, including the use of expired medications, incorrect patient, route, dose, or indication, can lead to inadequate, undesirable, and even dangerous drug effects.
An itemized list of single points of vulnerabilities
- The piercing device of the IV tubing can damage the wall of the secondary port.
- The various connections of the IV tubing with the fluid warmer, secondary infusion tubing, fluid warmer, and extensions can be loose and leak medications given.
- Contaminated ports of the IV-drug delivery system, used to administer medications.
- IV infiltration in the subcutaneous tissues.
- Syringe pumps malfunctions, failures, and disconnections.
- Drug expiration, route, indication, and dose checked.
Strategies for risk mitigation
Vigilance is of foremost importance in preventing and mitigating SPOV within the IV drug delivery system, but this should be done with an understanding of the vulnerabilities and the foresight to anticipate such consequences. This entails meticulous and thorough preparation, such as ensuring that the connections we make during line preparation are tight, that port sites are cleaned with antiseptic solutions before being used to inject medications, and rigorous pump programming with verification, ideally from a colleague.
Innovations and future directions
Exploring SPOV within other anesthesia systems opens avenues for further research and fosters continuous improvement and patient safety. Such systems include, but are not limited to, the anesthesia machine, Pyxis, airway instruments, ultrasound, and EMR.
Conclusion
“Prevention is better than cure” is a time-honored phrase, and we intend to use this quality educational tool to educate anesthesia providers on the importance of anticipation at the time of preparation.
Zulfiqar Ahmed is an anesthesiologist. Wouter Ritsema is a medical student. Nicholas Huang is an anesthesiology resident. Jeremy Voltz is a nurse anesthetist.
