[Man at risk. Preventive strategies and risk management for patient safety]

[Patient safety in anesthesiology : Multimodal strategies for perioperative care]

The concept of patient safety is more of a presence in modern day medicine than ever before. All measures and processes aiming at preempting and preventing critical incidents and accidents in patient care are collectively grouped under this concept. With the Declaration of Helsinki in 2010 modern anesthesiology has undertaken a fundamental role in the clinical implementation and perioperative clinicians are confronted with a multitude of theories, models, methods and tools targeted at improving or facilitating optimized patient safety. One of the biggest challenges lies in their synergistic combination to create a functioning concept for perioperative risk management while also incorporating individual strengths and weaknesses. The aim of the present paper is to provide a structured overview of the various components presently available for increasing perioperative patient safety.

[Simulation-based anaesthesia crisis resource management training. Results of a survey on learning success]

BACKGROUND

Up to as many as 38,000 people die in German hospitals each year as a result of preventable medical errors. Anesthetic procedures are generally safer than internal medical procedures and the mortality associated with anesthesia is estimated to be 3.3-5 cases per million. However, this is still 10 times higher than the risk associated with civilian aviation for example. Up to 80% of mistakes are attributable to inadequate execution of non-technical skills (NTS) such as communication, teamwork and organization of the working environment. Training in non-technical skills through Anesthesia Crisis Resource Management (ACRM) is an integral part of the Berlin Simulation Training (BeST) curriculum. The aim of this study was to describe the subjective evaluation of change in routine clinical behavior as a result of simulator training using latent outcome variables such as "subjective evaluation of learning outcome", with special emphasis on communication.

MATERIAL AND METHODS

In total 235 doctors with varying levels of professional experience received BeST training between 2001 and 2004. An anonymous postal questionnaire was sent to 228 of these participants and the response rate was 64% The questionnaire contained 13 questions covering evaluation of the workshop and learning outcome with respect to communication in the operating room (OR), teamwork in the OR and medical knowledge. Following factor analysis 3 latent outcome variables (subjective evaluation of the learning outcome, workshop-related change in perception of the value of communication and general value and relevance) were generated. Logistic regression was used to determine whether there was any relationship between the latent outcome variables and a number of independent factors.

RESULTS

It was not possible to demonstrate any relationship between the level of professional training, age or date of the workshop and the variables selected to describe subjective evaluation of behavioral change as a result of the workshop. How realistic the candidates perceived the training scenarios to be (p<0.01) and the sex of the candidates (p=0.03) were both significantly related to evaluation and female candidates were more likely to positively evaluate the simulator training. From the candidates' perspective the training significantly altered their perception of the value of NTSs, and in particular communication, during the management of critical incidents in the OR.

CONCLUSION

Well-staged and realistic simulation is associated with better learning outcomes. It may be important to take gender aspects into account in ACRM training.

[Perioperative fluid management: an analysis of the present situation]

Optimal perioperative fluid management is still controversial. Besides well known perioperative hypovolaemia, hypervolaemia has an influence on perioperative morbidity and mortality, particularly with regard to the patient's medical history, a reduced cardiac and pulmonal function and the operation itself. The concepts of preoperative, intraoperative and postoperative fluid administration are neither adequately validated, nor sufficiently integrated into a perioperative concept. At the present, moderate fluid administration to improve preoperative and postoperative outcome is safe in minor or medium surgical procedures. High-risk surgical patients benefit from a time-oriented or/and goal-oriented monitored fluid therapy. In the past only little attention has been concentrated on postoperative fluid management, but may be stimulated by the new concepts of fast track surgery.

[Anonymous critical incident reporting system. Implementation in an intensive care unit]

In 2003 an anonymous reporting system for critical incidents was implemented in the Department of Anaesthesiology and Intensive Care Medicine of the University Hospital Dresden. This reporting system was modified to an intranet-based version and extended to the intensive care unit (ICU). During the first 18 months 70 anonymous reports originating from the ICU were registered. The most common errors involved fluid management, followed by errors in airway management, cardio-vascular management, neurological problems and errors in drug administration. The main causes were lack of attention, missing check of measures, work load of nurses, experience and communication deficits. The article discusses the incidence of errors in the ICU setting and their potential effects.

[Teaching and simulation. Methods, demands, evaluation and visions]

Since 1st October 2003 the new German "Approbationsordnung für Arzte" (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training program. Basic requirements for a successful training program using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor-student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios "induction of anaesthesia", "acute pulmonary embolism", "acute management of a multiple trauma patient" and "postoperative hypotension" as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1-6. These scores were better than those given for other segments of the curriculum.

Anonymes Meldesystem kritischer Ereignisse in der Anästhesie

Two years ago we implemented a reporting system for critical incidents in the Department of Anaesthesiology and Intensive Care of the University Hospital Dresden. During the first 18 months 162 anonymous reports were registered. The most common errors involved airway and ventilation management, followed by errors in fluid and cardio-vascular management. The main causes were distraction, lack of experience, specific training and communication deficits. The confidence in the anonymity of the reporting system was very high. Following the analysis of the reports, several modifications were initiated, e.g. specific training programs or definition of standards. Over time, a change in the relative distribution of reported errors was observed. The article discusses the different kinds of errors and possible countermeasures. It also strengthens several aspects which are important to consider during the initial phase of a local critical incident reporting system.

Klinisches Risikomanagement

BACKGROUND

The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety.

MATERIALS AND METHODS

A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented.

RESULTS

The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period.

CONCLUSIONS

Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).

[Death on the operating table. Anesthesiologic and medicolegal aspects]

Since death on the operating table is a relatively rare incident, it raises a number of special medicolegal questions that are discussed in this article. One of the major concerns for medical personnel is being accused of malpractice during treatment, as it is an obvious presumption on the part of laymen that death was directly related to the medical treatment as compared with other in-hospital deaths. Questions such as who is responsible for issues of informed consent and liability are discussed. Other important aspects such as communication with the bereaved, transparent chronological documentation of the death circumstances, questions regarding certification of death, questions arising from autopsy done to determine the reason of death, questions about malpractice, legal requirements concerning confidential medical communication and information about what must be sent to the professional indemnity insurance company are elucidated. There is also some special information presented for cases that involve the deaths of Jehovah's Witnesses.

Simulatorgestütztes, modulares Human Factors Training in der Anästhesie

BACKGROUND

Human factors (HF) play a major role in crisis development and management and simulator training can help to train HF aspects. We developed a modular training concept with psychological intensive briefing. The aim of the study was to see whether learning and transfer in the treatment group (TG) with the module "communication and team-cooperation" differed from that in the control group (CG) without psychological briefing ("anaesthesia crisis resource management type course").

METHODS

A total of 34 residents (TG: n=20, CG: n=14) managed 1 out of 3 scenarios and communication patterns and management were evaluated using video recordings. A questionnaire was answered at the end of the course and 2 months later participants were asked for lessons learnt and behavioral changes.

RESULTS

Good communication and medical management showed a significant correlation (r=0.57, p=0.001). The TG showed greater initiative ( p=0.001) and came more often in conflict with the surgeon ( p=0.06). The TG also reported more behavioral changes than the CG 2 months later. The reported benefit of the simulation was training for rare events in the CG, whereas in the TG it was issues of communication and cooperation ( p=0.001).

CONCLUSIONS

A training concept with psychological intensive briefing may enhance the transfer of HF aspects more than classical ACRM.