Wake Up Safe Update
By Manon Hache, MD
Columbia University, New York
David Buck, MD
Cincinnati Children’s Hospital, Cincinnati
Don Tyler, MD
Children’s Hospital of Philadelphia, Philadelphia
Wake Up Safe is a Patient Safety Organization, as designated by the Agency for Healthcare Research and Quality (AHRQ). Since its inception in 2008, it has grown to include 32 member institutions.
There are three components to the organization:
- A registry for serious adverse events among the participating institutions.
This includes demographic data for all patients cared for by each participating institution as well as serious adverse event data according to predetermined criteria. - Quality improvement projects designed to reduce the occurrence of adverse events.
Each institution receives education related to Safety analytics and Quality improvement methodology and is encouraged to lead quality improvement projects in their own institution. - Peer visits to institutions identify best practices and make recommendations about processes that could be improved.
Since we last updated SPA members, we have continued to actively work on data integrity. We have reported 3,849 events in 2,946,741 patients. The most common events reported are respiratory events (23.1%) and cardiac arrests (21.8%). There have been 214 perioperative deaths (within 24h) reported (5.6% of all events reported). It is notable that there were no anesthesia related deaths in ASA one or two patients. This reaffirms the continued improvement in the safety of pediatric anesthesia care in recent years.
The Wake Up Safe educational curriculum has continued with both fundamental and advanced workshops in safety analytics and quality improvement. We provided a fundamental workshop in QI through SPA at the March meeting in Austin. In addition, Erin Ahrens, from Nationwide Children’s, gave an advanced workshop on Root Cause Analysis. At each meeting, members present QI projects they are working on to the group for feedback. Workshops are also available to non-Wake Up Safe members.
Our site visits have helped us to identify barriers to improvement work and to communicate these findings to hospital leadership. We are updating and standardizing our process for site visits. We are also including on site quality improvement coaching and education.
Wake Up Safe tracks the QI capability of its member institutions through milestones and objectives. This helps the group tailor its education and support to the group’s individual needs and track our QI capability over time.
Recently, Wake Up Safe published a statement regarding spinal cord infarction or injury risk in patients with Mucopolysaccharidosis (MPS) (Safe, 2017). These patients are known to have difficult airways and potential cervical spine instability. In the recent past, two cases of paralysis after combined general and epidural anesthesia were reported prompting a recommendation to avoid neuraxial blocks in these patients, and to be particularly careful with positioning and even consider spinal cord monitoring. Patients with kyphosis and those with the potential for prolonged surgery or significant blood loss may be at higher risk.
This year, a paper reviewing cardiac arrests in the post anesthesia care unit (PACU) reported in the Wake Up Safe database was published in Anesthesia & Analgesia. (Christensen, Bishr, & Voepel-Lewis, 2017). Also, recently, a paper reviewing medication errors was published and chosen article of the month by the Anesthesia & Analgesia Editorial Board for September 2017 (Lobough LMY, 2017).
In conclusion, Wake Up Safe continues to grow as a patient safety organization. It strives to continue to advocate for patient safety, encouraging its participating institutions to engage in quality improvement projects, participate in peer evaluation site visits, as well as learn Safety Analytics and Quality Improvement methodology.
