JCAHO and Recall

Specialties CRNA

Published

Has anyone heard of this new "JCAHO sentinal event alert" regarding recall? As the department chief, does this mean I have to buy the BIS or PSA monitor. Is there a way to get around the issue without having to spend the $$$$ and comprising care? I have tried both monitors because of the sales rep pressure. I still am not sold on the science and reliability. In the end they (the reps) have told me that they will not stand by their machines 100% but its just an adjunct. In my opinion, Bezos, N2O, and volatile agents are enough. What happened to vigilance? If your patient is light , in most instances you should be able to tell...Anyways, any feedback will be well appreciated.\

Thanks,

Mike CRNA

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Specializes in Vents, Telemetry, Home Care, Home infusion.

sentinel event alert.

issue 32 - october 6, 2004

preventing, and managing the impact of, anesthesia awareness

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having had this happen to me, i'm accurely aware of issue.

especially like these recomendations:

managing the impact of anesthesia awareness

as noted above, anesthesia awareness cannot always be prevented. health care practitioners must therefore be prepared to acknowledge and manage the occurrence of anesthesia awareness with compassion and diligence. this management includes the following suggestions for patients who report awareness (4):

  • interview the patient after the procedure, taking a detailed account of his or her experience and include it in the patient's chart.
  • apologize to the patient if anesthesia awareness has occurred.
  • assure the patient of the credibility of his or her account and sympathize with the patient's suffering.
  • explain what happened and its reasons, e.g., the necessity to administer light anesthesia in the presence of significant cardiovascular instability.
  • offer the patient psychological or psychiatric support, including referral of the patient to a psychiatrist or psychologist.
  • notify the patient's surgeon, nurse and other key personnel about the incident and the subsequent interview with the patient.

surgical team members should also be educated about anesthesia awareness and its management.

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"interview the patient after the procedure, taking a detailed account of his or her experience and include it in the patient's chart."

if this had occured in the facility i was in, it would have greatly reduced my anxiety and maybe prevent the panic attack (first ever) i had following week home and anxiety over future surgery/anesthesia needs. my letter to hospital ceo did result in 2 calls from anesthesia dept chair and i now carry his beeper number with me. subsequent surgery/anesthesia went off without a hitch...3 months since first problem, still uneasy recalling what i went thru. they now have updated policy and procedures too along with staff inserviced.

jcaho not saying you have to purchase these machines, just have policy and procedures in place to minimize, be able to identify high risk patients and have good followup if anesthesia awareness reported.

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Has anyone heard of this new "JCAHO sentinal event alert" regarding recall? As the department chief, does this mean I have to buy the BIS or PSA monitor. Is there a way to get around the issue without having to spend the $$$$ and comprising care? I have tried both monitors because of the sales rep pressure. I still am not sold on the science and reliability. In the end they (the reps) have told me that they will not stand by their machines 100% but its just an adjunct. In my opinion, Bezos, N2O, and volatile agents are enough. What happened to vigilance? If your patient is light , in most instances you should be able to tell...Anyways, any feedback will be well appreciated.\

Thanks,

Mike CRNA

You need to actually read the material from JCAHO before you panic. There is no requirement to purchase anything.

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