Patient Safety, Professionalism, and Perioperative Medicine
Patient Safety
Frameworks to know
The Swiss cheese model describes accidents as failures of multiple defensive layers aligning. A near miss causes no harm and is still reportable; an adverse event is harm regardless of preventability; an error is a deviation from intended action. Root cause analysis is a systems-focused response to a sentinel event, explicitly avoiding individual blame, in contrast to a morbidity and mortality conference that may emphasize individual decision-making. Just culture holds people accountable for reckless behavior while treating honest errors as system signals.
Recurring harm themes
Closed-claims data consistently place respiratory events, nerve injury from positioning, and medication errors near the top of anesthesia-related harm. Medication safety hinges on look-alike, sound-alike labeling, weight-based pediatric calculations with independent double-checks, and standardized concentrations. Alarm fatigue is a genuine safety hazard, so alarms must be audible, visible, and appropriately configured rather than disabled. The Universal Protocol - verification, marking, and time-out - targets wrong-site surgery, and retained foreign body prevention depends on structured counts and, where used, radiofrequency detection.
Crises and communication
Malignant hyperthermia presents with unexplained rising end-tidal CO2, rigidity, hyperkalemia, and acidosis; dantrolene 2.5 mg/kg is the first step, repeatable to a 10 mg/kg total, alongside stopping triggers, hyperventilation with 100% oxygen, and cooling. Structured handoffs reduce information loss at transitions of care, and disclosure of harm to patients and families is both an ethical and a safety obligation.
Worked example
A 70 kg patient in suspected malignant hyperthermia: dantrolene 2.5 × 70 = 175 mg, which is about 9 vials of 20 mg, reconstituted rapidly and repeated until the crisis abates.
Professionalism and Perioperative Medicine
Consent, capacity, and ethics
Valid informed consent requires capacity, adequate disclosure of risks and alternatives, comprehension, and voluntariness; a signature alone is not consent. Capacity is a clinical determination, while competence is legal. When a patient lacks capacity and no advance directive exists, turn to the surrogate hierarchy defined by state law. Do-not-resuscitate orders should be reviewed explicitly before surgery rather than silently suspended or silently carried into the operating room, and they should be revisited after recovery. Impaired colleagues, conflicts of interest, and errors require disclosure and reporting through defined channels; concealment is the professionalism failure that questions target.
Perioperative medicine
Risk stratification uses the Revised Cardiac Risk Index and functional capacity, with natriuretic peptide or stress testing reserved for patients who will change management. Continue chronic beta blockers, but do not start them on the day of surgery. For anticoagulation, DOACs generally need no bridging; warfarin bridging is reserved for high thrombotic risk, with timing guided by procedure bleed risk. Hold SGLT2 inhibitors for several days and follow current guidance for GLP-1 receptor agonists regarding gastric emptying. Enhanced recovery principles - multimodal opioid-sparing analgesia, avoidance of prolonged fasting, early feeding and ambulation - reduce length of stay. Smoking cessation at least 4 weeks before surgery lowers pulmonary complications.
Worked example
A patient on apixaban for atrial fibrillation with a CHA2DS2-VASc of 3 undergoing a low-bleed-risk procedure: hold the drug for the interval dictated by renal function and restart soon after; do not bridge with heparin, which adds bleeding without reducing stroke.
Trap
Questions frequently equate stopping an anticoagulant with safety. The real axis is thrombotic risk versus procedural bleeding risk, and bridging is the exception, not the default.