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Juarez-Sanchez A, Heras Hernando V, Brunete Jimenez T, Molina Mendoza CR, Arnal Velasco D, Fernández Téllez L. How a single perioperative delirium case can make the difference. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00064-7. [PMID: 38615714 DOI: 10.1016/j.redare.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/16/2024] [Indexed: 04/16/2024]
Abstract
This report describes how postoperative delirium in an elderly man during COVID-19 pandemic led to a serious event involving a central venous catheter. Delirium is a common cause of perioperative morbidity and mortality, and is characterised by an alteration in consciousness and perception and a reduced ability to focus, sustain or shift attention. The event was analysed by a multidisciplinary committee which developed a risk stratification delirium protocol in order to prevent similar events in the future.
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Affiliation(s)
- A Juarez-Sanchez
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain.
| | - V Heras Hernando
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain
| | - T Brunete Jimenez
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain
| | - C R Molina Mendoza
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain
| | - D Arnal Velasco
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain
| | - L Fernández Téllez
- Servicio de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain
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Abstract
PURPOSE OF REVIEW Learning from errors has been the main objective of patient safety initiatives for the last decades. The different tools have played a role in the evolution of the safety culture to a nonpunitive system-centered one. The model has shown its limits, and resilience and learning from success have been advocated as the key strategies to deal with healthcare complexity. We intend to review the recent experiences in applying these to learn about patient safety. RECENT FINDINGS Since the publication of the theoretical basis for resilient healthcare and Safety-II, there is a growing experience applying these concepts into reporting systems, safety huddles, and simulation training, as well as applying tools to detect discrepancies between the intended work as imagined when designing the procedures and the work as done when front-line healthcare providers face the real-life conditions. SUMMARY As part of the evolution in patient safety science, learning from errors has its function to open the mindset for the next step: implementing learning strategies beyond the error. The tools for it are ready to be adopted.
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Affiliation(s)
- Daniel Arnal-Velasco
- Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain
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Gibbs NM, Culwick MD, Endlich Y, Merry AF. A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Anaesth Intensive Care 2021; 49:422-429. [PMID: 34894746 DOI: 10.1177/0310057x211060846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.
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Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, 5728Sir Charles Gairdner Hospital, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yasmin Endlich
- Department of Anaesthesia, Royal Adelaide Hospital and Women and Children's Hospital, Adelaide, Australia
| | - Alan F Merry
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand This article is a copy of a report submitted to the Australian and New Zealand Tripartite Anaesthesia Data Committee (ANZTADC). It is published on behalf of ANZTADC at their request and with their permission. It has not been subject to peer review
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Hegarty J, Flaherty SJ, Saab MM, Goodwin J, Walshe N, Wills T, McCarthy VJ, Murphy S, Cutliffe A, Meehan E, Landers C, Lehane E, Lane A, Landers M, Kilty C, Madden D, Tumelty M, Naughton C. An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review. J Patient Saf 2021; 17:e1247-e1254. [PMID: 32271529 PMCID: PMC8612884 DOI: 10.1097/pts.0000000000000700] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. METHODS Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. RESULTS A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as "never events," "serious reportable events," or "always review and report" were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. CONCLUSIONS Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety.
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Affiliation(s)
| | | | | | - John Goodwin
- From the Catherine McAuley School of Nursing and Midwifery
| | - Nuala Walshe
- From the Catherine McAuley School of Nursing and Midwifery
| | - Teresa Wills
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Siobhan Murphy
- From the Catherine McAuley School of Nursing and Midwifery
| | - Alana Cutliffe
- From the Catherine McAuley School of Nursing and Midwifery
| | - Elaine Meehan
- From the Catherine McAuley School of Nursing and Midwifery
| | - Ciara Landers
- From the Catherine McAuley School of Nursing and Midwifery
| | - Elaine Lehane
- From the Catherine McAuley School of Nursing and Midwifery
| | - Aoife Lane
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Caroline Kilty
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Mary Tumelty
- School of Law, University College Cork, Cork, Ireland
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Fujita S, Seto K, Hatakeyama Y, Onishi R, Matsumoto K, Nagai Y, Iida S, Hirao T, Ayuzawa J, Shimamori Y, Hasegawa T. Patient safety management systems and activities related to promoting voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues: A cross-sectional study. PLoS One 2021; 16:e0255329. [PMID: 34320041 PMCID: PMC8318237 DOI: 10.1371/journal.pone.0255329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 07/15/2021] [Indexed: 11/18/2022] Open
Abstract
Both voluntary in-hospital reporting and mandatory national-level reporting systems for patient safety issues need to work well to develop a patient safety learning system that is effective in preventing the recurrence of adverse events. Some of the hospital systems and activities may increase voluntary in-hospital reporting and mandatory national-level reporting. This study aimed to identify the hospital systems and activities that increase voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues. An anonymous mail survey of hospitals in Japan was conducted in 2017. The hospitals were selected by stratified random sampling according to number of beds. The survey examined the annual number of reported events in the voluntary in-hospital reporting system for patient safety and experience of reporting unexpected patient deaths possibly due to medical interventions to the mandatory national-level reporting system in the last 2 years. The relationship of the answer to the questions with the patient safety management systems and activities at each hospital was analyzed. The response rate was 18.8% (603/3,215). The number of in-hospital reports per bed was positively related to identifying events by referring complaints or questions of patients or family members, using root cause analysis for analyzing reported events, and developing manuals or case studies based on reported events, and negatively related to the unification and standardization of medical devices and equipment. The experience with mandatory national-level reporting of serious adverse events was positively related to identifying problematic cases by a person in charge of patient safety management from the in-hospital reporting system of complications and accidental symptoms. Enhanced feedback for reporters may promote voluntary in-hospital reporting of minor cases with low litigation risks. Developing an in-hospital mechanism that examines all serious complications and accidental symptoms may promote mandatory national-level reporting of serious adverse events with high litigation risks.
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Affiliation(s)
| | - Kanako Seto
- Toho University School of Medicine, Tokyo, Japan
| | | | - Ryo Onishi
- Toho University School of Medicine, Tokyo, Japan
| | | | - Yoji Nagai
- Hitachinaka General Hospital, Ibaraki, Japan
| | - Shuhei Iida
- Nerima General Hospital, Tokyo, Japan
- Institute for Healthcare Quality Improvement, Tokyo, Japan
| | | | - Junko Ayuzawa
- Faculty of Medical Science, Kyushu University, Fukuoka, Japan
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Budi SC, Hapsara S, Tetra FS, Lazuardi L. Incident Report: Between the Shadows of Obligation and Formality. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Incident reports are the primary data source for monitoring patient safety in the hospital. Monitoring of these reports determines the success of managing safety-related incidents as an effort to improve patient care. Hospital staff plays an essential role in the management of incident reports. Each staff member has a role in managing incident reports.
AIM: This article aimed to explore the role of hospital staff in the incident reporting process.
METHODS: This qualitative research used an exploratory approach. The research informants were three doctors, 21 nurses, one pharmacist, and two computer administrators. Data were collected using interviews and observations of incident reporting implementation. The research data were analyzed with the qualitative analysis software Atlas.ti.
RESULTS: Report management is not done solely for the formality of achieving the target. Implementation of regulations for report management is also done by all hospital staff to prioritize discipline, honesty, and responsibility according to their roles. Staff is expected to report adverse or dangerous events (incidents) that could affect patient safety. The reporting coordinator is responsible for the report’s completeness. Heads of participation room are expected to validate reports. The patient safety team is in charge of analyzing and providing feedback. Supportive attitudes from the board of directors are needed to create a reporting culture. There are several barriers to reporting management, including management support factors, facilities, and an effective feedback system.
CONCLUSION: Leaders need to develop staff who focus on discipline, honesty, and responsibility in providing services to patients by prioritizing patient safety. All staff is involved in managing incident reports by playing an active role in following their duties.
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Burgess J, Asfaw G, Moore J. Adverse events during anaesthesia at an Ethiopian referral hospital: a prospective observational study. Pan Afr Med J 2021; 38:375. [PMID: 34367454 PMCID: PMC8308963 DOI: 10.11604/pamj.2021.38.375.24711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 04/14/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction incident reporting systems are widely utilised within healthcare to analyse adverse events and have been shown to reduce patient harm. With data to suggest high anaesthetic-related mortality in low and middle-income countries (LMICs), such systems could allow more accurate determination of rates and types of incidents and could improve patient safety. Methods this prospective observational study carried out over six-weeks in March to April 2019 in an Ethiopian tertiary referral hospital, included direct observations in the operating room and recording of any anaesthesia-related adverse events occurring during the perioperative period. Results fifty surgical cases were observed during weekday daytime hours. Sixteen anaesthesia-related adverse events were observed in 12 patients, including six elective cases and six emergencies, an adverse event rate of 32% (n=16), affecting 24% (n=12) of patients. Most incidents occurred in infants less than one-year-old and those between 11-20 years (31.3%; n=5 each) and those undergoing general anaesthesia (66.7%; n=8), particularly during the induction phase (50%; n=8), the most common event being prolonged desaturation (31.3%; n=5). Most events were considered to contribute a low level of harm (56.3%; n=9). There were no intra-operative mortalities. Conclusion this study presents evidence of a higher rate of adverse events during anaesthesia at a tertiary referral hospital in Ethiopia, than reported in current literature from LMICs. There is potential for large volume data to be produced and learnt from with a reporting system in place in this setting. The most common event was desaturation detected by pulse oximetry, particularly in paediatric surgery.
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Affiliation(s)
- Joe Burgess
- National Health Service (NHS) Grampian, Aberdeen, United Kingdom
| | - Gebrehiwot Asfaw
- Department of Anaesthesia, Bahir Dar University, Bahir Dar, Ethiopia
| | - Jolene Moore
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
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Zhang X, Ma S, Sun X, Zhang Y, Chen W, Chang Q, Pan H, Zhang X, Shen L, Huang Y. Composition and risk assessment of perioperative patient safety incidents reported by anesthesiologists from 2009 to 2019: a single-center retrospective cohort study. BMC Anesthesiol 2021; 21:8. [PMID: 33413123 PMCID: PMC7789294 DOI: 10.1186/s12871-020-01226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/25/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patient safety incident (PSI) reporting has been an important means of improving patient safety and enhancing organizational quality control. Reports of anesthesia-related incidents are of great value for analysis to improve perioperative patient safety. However, the utilization of incident data is far from sufficient, especially in developing countries such as China. Methods All PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and August 2019 were collected from the incident reporting system. We reviewed the freeform text reports, supplemented with information from the patient medical record system. Composition analysis and risk assessment were performed. Results In total, 847 PSIs were voluntarily reported by anesthesiologists during the study period among 452,974 anesthetic procedures, with a reported incidence of 0.17%. Patients with a worse ASA physical status were more likely to be involved in a PSI. The most common type of incident was related to the airway (N = 208, 27%), followed by the heart, brain and vascular system (N = 99, 13%) and pharmacological incidents (N = 79, 10%). Those preventable incidents with extreme or high risk were identified through risk assessment to serve as a reference for the implementation of more standard operating procedures by the department. Conclusions This study describes the characteristics of 847 PSIs voluntarily reported by anesthesiologists within eleven years in a Chinese academic hospital. Airway incidents constitute the majority of incidents reported by anesthesiologists. Underreporting is common in China, and the importance of summarizing and utilizing anesthesia incident data should be scrutinized.
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Affiliation(s)
- Xue Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Shuang Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Xueqin Sun
- Department of West Campus Medical Affairs, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Damucang Alley 41#, Xicheng District, Beijing, China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, China
| | - Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Qing Chang
- Department of Medical Affairs, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, China
| | - Hui Pan
- Department of Medical Affairs, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, China
| | - Xiuhua Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
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Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey. Eur J Anaesthesiol 2020; 36:946-954. [PMID: 31268913 DOI: 10.1097/eja.0000000000001043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN Online survey. SETTING A total of 38 countries within Europe. PARTICIPANTS Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement.
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Arnal-Velasco D, Barach P. Anaesthesia and perioperative incident reporting systems: Opportunities and challenges. Best Pract Res Clin Anaesthesiol 2020; 35:93-103. [PMID: 33742581 DOI: 10.1016/j.bpa.2020.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 12/20/2022]
Abstract
Incident Reporting Systems (IRS) continue to be an important influence on improving patient safety. IRS can provide valuable insights into how to prevent patients from being harmed at the organizational level. But inadequate expectations and misuse, for performance assessment, patient safety measurement or research, have hindered the full IRS potential. Health care organizations need to develop effective strategies built on trust and truth telling to improve the impact of IRS. This requires strategies to address the limited resources to analyse the near-misses or adverse events; avoid the punitive drift through maintaining the anonymity and protective legislation; integrating IRS and avoiding its confusion with mandatory adverse event response systems; training data analysts to focus on the system instead of the individual through a balanced simple taxonomy; combine the analyses at the local level, to reinforce effective and personalized feedback, with the potential of a national or supranational learning platform.
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Affiliation(s)
- Daniel Arnal-Velasco
- Department of Anaesthesiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
| | - Paul Barach
- Children's Hospital, Wayne State University School of Medicine Hospital, MI, USA; Jefferson College of Population Health, PA, USA
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Gautam B, Shrestha BR. Critical Incidents during Anesthesia and Early Post-Anesthetic Period: A Descriptive Cross-sectional Study. ACTA ACUST UNITED AC 2020; 58:240-247. [PMID: 32417861 PMCID: PMC7580454 DOI: 10.31729/jnma.4821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes. Studying those helps detect problems, which is crucial in minimizing their recurrence. We aimed to identify the frequency of peri-anesthetic critical incidents. METHODS This is a hospital-based descriptive cross-sectional study of voluntarily reported incidents, which occurred during anesthesia or following 24 hours among patients subjected to non-cardiac surgery within the calendar year 2019. Patient characteristics, anesthesia, and surgery types, category, context, and outcome of incidents were recorded in an indigenously designed form. Incidents were assigned to attributable (patient, anesthesia or surgery) factor, and were analyzed for the system,equipment or human error contribution. RESULTS Altogether 464 reports were studied, which consisted of 524 incidents. Cardiovascular category comprised of 345 (65.8%) incidents. Incidents occurred in 433 (93%) otherwise healthy patients and during 258 (55.6%) spinal anesthetics. Obstetric surgery was involved in 179 (38.6%) incidents. Elective surgery and anesthesia maintenance phase included the context in 293 (63%)and 378 (72%) incidents respectively. Majority incidents 364 (69.5%) were anesthesia-attributable, with system and human error contribution in 196 (53.8%) and 152 (41.7%) cases respectively. All recovered fully except for 25 cases of mortality, which were mostly associated with patient factors, surgical urgency, and general anesthesia. CONCLUSIONS Critical incidents occur even in low-risk patients during anesthesia delivery. Patient factors and emergency surgery contribute to the most serious incidents.
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Affiliation(s)
- Binod Gautam
- Department of Anesthesia and Intensive Care, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal
| | - Babu Raja Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal
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Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system. Br J Anaesth 2020; 124:197-205. [DOI: 10.1016/j.bja.2019.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/28/2019] [Accepted: 10/06/2019] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW Many possible hazards bedevil the perioperative patient. This review focuses on a number of aspects of perioperative management where the patient's quality and safety can be enhanced. RECENT FINDINGS Our understanding of the relationship between preoperative preparation and postoperative outcomes has improved. There have also been recent developments in our understanding of how to construct useful cognitive aids and make the best use of checklists by understanding the cultural environment supporting their use. Postoperatively, the concept of 'failure to rescue' in the surgical patients has been explored. SUMMARY A clear vision of what postoperative recovery should mean for practitioner and patients; careful risk stratification and prophylactic measures to avoid postoperative complications; the judicious use of checklists and other cognitive aids to complement clinical expertise in promoting safety within each local context; and the prompt recognition and rescue of postoperative problems when they occur are all important aspects of a safe perioperative care.
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Caba Barrientos F, Rodríguez Morillo A, Galisteo Domínguez R, Del Nozal Nalda M, Almeida González CV, Echevarría Moreno M. What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group. ACTA ACUST UNITED AC 2018; 65:258-268. [PMID: 29373190 DOI: 10.1016/j.redar.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/12/2017] [Accepted: 12/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS). MATERIAL AND METHOD Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed. RESULTS Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken. CONCLUSIONS The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels.
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Affiliation(s)
- F Caba Barrientos
- Grupo local de SENSAR, Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España.
| | - A Rodríguez Morillo
- Grupo local de SENSAR, Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - R Galisteo Domínguez
- Subdirección de Enfermería del Bloque Quirúrgico, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - M Del Nozal Nalda
- Subdirección Médica y Calidad del Bloque Quirúrgico, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - C V Almeida González
- Unidad de Metodología y Estadística de Investigación, Universidad de Sevilla, Sevilla, España
| | - M Echevarría Moreno
- Dirección de la Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
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16
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Potts N, Martin DS, Hoy L. Critical incident analysis: Equip to avoid failure. J Perioper Pract 2018; 27:77-81. [PMID: 29328747 DOI: 10.1177/175045891702700403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 07/29/2016] [Indexed: 11/15/2022]
Abstract
This work is set in the context of perioperative practice in difficult airway management. It integrates a root cause analysis and fish bone technique to investigate a critical incident in temporary yet crucial equipment failure. Risk management and incident reporting is analysed alongside human factors in the operating theatre environment. Finally, recommendations for risk reduction, vigilance and checking vital airway equipment are made in anaesthetic practice.
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Affiliation(s)
- Naomi Potts
- Operating Theatre Department, Belfast City Hospital, UK
| | | | - Leontia Hoy
- School of Nursing and Midwifery, Queen's University Belfast, UK
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17
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Mjadu T, Jarvis M. Patients’ safety in adult ICUs: Registered nurses’ attitudes to critical incident reporting. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2018. [DOI: 10.1016/j.ijans.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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18
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Petschnig W, Haslinger-Baumann E. Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40886-017-0060-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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19
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Şalvız EA, Edipoğlu Sİ, Sungur MO, Altun D, Büget Mİ, Seyhan TÖ. Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study. Turk J Anaesthesiol Reanim 2016; 44:59-70. [PMID: 27366560 DOI: 10.5152/tjar.2016.75133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/30/2015] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. METHODS One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs. RESULTS Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1-5]/10 and 3 [1-5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1-5]/10 (p=0.498). CONCLUSION This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health.
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Affiliation(s)
- Emine Aysu Şalvız
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Saadet İpek Edipoğlu
- Clinic of Anaesthesiology, Süleymaniye Training and Research Hospital, İstanbul, Turkey
| | - Mukadder Orhan Sungur
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Demet Altun
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Mehmet İlke Büget
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Tülay Özkan Seyhan
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
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20
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Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A. International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ Qual Saf 2016; 26:150-163. [PMID: 26902254 DOI: 10.1136/bmjqs-2015-004456] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/10/2016] [Accepted: 01/24/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. OBJECTIVE To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. METHODS After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. RESULTS Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. CONCLUSIONS We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.
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Affiliation(s)
- Ann-Marie Howell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Elaine M Burns
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
| | - Louise Hull
- Division of Surgery, Imperial College London, London, UK
| | - Erik Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nick Sevdalis
- Department of Surgery and Cancer, Imperial College London, London, UK.,Health Service and Population Research, Centre for Implementation Science, King's College, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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21
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Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiol 2016; 16:4. [PMID: 26772179 PMCID: PMC4715310 DOI: 10.1186/s12871-016-0172-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/14/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS). METHODS Two experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making. RESULTS SA errors were identified in 81.5%. Predominantly, errors occurred on the levels of perception (38.0%) and comprehension (31.5%). Errors on the level of projection played a minor role (12.0%). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance. CONCLUSIONS SA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.
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Affiliation(s)
- Christian M Schulz
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.
| | - Veronika Krautheim
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Annika Hackemann
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Eberhard F Kochs
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Klaus J Wagner
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
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Cronjé L. A review of paediatric anaesthetic-related mortality, serious adverse events and critical incidents. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2015. [DOI: 10.1080/22201181.2015.1119503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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23
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Davies JM, Steinke C. Concepts of safety reporting. Can J Anaesth 2015; 62:1233-8. [DOI: 10.1007/s12630-015-0491-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 09/01/2015] [Accepted: 09/11/2015] [Indexed: 10/23/2022] Open
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24
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Rutherford JS, Flin R, Irwin A. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008. Anaesth Intensive Care 2015; 43:512-7. [PMID: 26099766 DOI: 10.1177/0310057x1504300416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.
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Affiliation(s)
- J S Rutherford
- Consultant Anaesthetist, Department of Anaesthesia, Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom
| | - R Flin
- Professor of Applied Psychology, Department of Psychology, University of Aberdeen, Aberdeen, United Kingdom
| | - A Irwin
- Teaching Fellow, Department of Psychology, University of Aberdeen, Aberdeen, United Kingdom
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25
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Bohnet-Joschko S, Zippel C, Siebert H. [Prevention of medical device-related adverse events in hospitals: Specifying the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2015; 109:725-35. [PMID: 26699261 DOI: 10.1016/j.zefq.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 05/27/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The use and organisation of medical technology has an important role to play for patient and user safety in anaesthesia. OBJECTIVES Specification of the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment, explore opportunities and challenges for the safe use and organisation of anaesthesia devices. METHODS We conducted a literature search in Medline/PubMed for studies dealing with the APS recommendations for the prevention of medical device-related risks in the context of anaesthesia. In addition, we performed an internet search for reports and recommendations focusing on the use and organisation of medical devices in anaesthesia. Identified studies were grouped and assigned to the recommendations. The division into users and operators was maintained. RESULTS Instruction and training in anaesthesia machines is sometimes of minor importance. Failure to perform functional testing seems to be a common cause of critical incidents in anaesthesia. There is a potential for reporting to the federal authority. Starting points for the safe operation of anaesthetic devices can be identified, in particular, at the interface of staff, organisation, and (anaesthesia) technology. CONCLUSIONS The APS recommendations provide valuable information on promoting the safe use of medical devices and organisation in anaesthesia. The focus will be on risks relating to the application as well as on principles and materials for the safe operation of anaesthesia equipment.
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Affiliation(s)
- Sabine Bohnet-Joschko
- Walcker-Stiftungsprofessur für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaftswissenschaft, Universität Witten/Herdecke, Witten, Deutschland.
| | - Claus Zippel
- Walcker-Stiftungsprofessur für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaftswissenschaft, Universität Witten/Herdecke, Witten, Deutschland
| | - Hartmut Siebert
- Aktionsbündnis Patientensicherheit e. V., Berlin, Deutschland
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