A patient laying on a  hospital bed receiving oxygen.
Patient History Alerts Keep Staff Informed and Prepared

​In some patients, anesthetics can cause a severe, sometimes lethal, reaction known as malignant hyperthermia (MH), with symptoms such as a dangerously high body temperature, rigid muscles or spasms, and a rapid heart rate. It is important to communicate a history of MH to operating room (OR) staff before a surgical procedure, but at one hospital in 2017, the surgeon’s office did not inform Scheduling, Anesthesia, or the OR of the patient’s history of MH. Fortunately, it was identified immediately preop and the team took appropriate precautions, resulting in no harm to the patient. However the near miss prompted the Preadmission Center clinical leader and the OR operations manager to investigate the incident to prevent this from happening again, and the clinical risk coordinator referred the issue to the health information technology (Health IT) team and requested an alert to fire when a patient with a history or family history of MH is being planned for surgery. As a result, a multidisciplinary team comprised of Anesthesiology, Preadmission Testing, OR, Health IT, and Risk Management developed new case alerts in the electronic health record for MH. These alerts fire warnings in the form of a patient alert banner (“Patient has a history of malignant hyperthermia.”) when a documented history of MH is entered for the patient, whether during scheduling or pre-anesthesia testing or visit, or by OR nurses, the surgeon, or anesthesia, with reminders to follow the facility’s procedures for notifying OR and Anesthesia leadership and update the case comments and medical record. ​​​​