The Australian Incident Monitoring Study: an analysis of 2000 incident reports

Registries in pediatric anesthesiology: A brief history and a new way forward

Clinical registries are multicenter prospective observational datasets that have been used to examine current perioperative practices in pediatric anesthesia. These datasets have proven useful in quantifying the incidence of rare adverse outcomes. Data from registries can highlight associations between severe patient safety events and patient and procedure-related risk factors. Registries are an effective tool to delineate practices and outcomes in niche patient populations. They have been used to quantify uncommon complications of medications and procedures. Registries can be used to generate knowledge and to support quality improvement. Multicenter engagement can promote best clinical practices and foster professional networks. Registries are limited by their observational nature, which entails a lack of randomization as well as selection and treatment bias. The maintenance of registries over time can be challenging due to difficulties in modifying the included variables, collaborator fatigue, and continued outlay of resources to maintain the database and onboard new sites. These latter issues can lead to decreased data quality. In this article, we discuss key insights from several pediatric anesthesia registries and propose a new type of registry that addresses some shortcomings of the current paradigm.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

INTRODUCTION

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.

RESULTS

We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.

CONCLUSIONS

This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.

Anesthesiologists in the Ether: Technology and Telemedicine in Anesthesiology

A new frontier in veterinary anesthesia telehealth has begun. With the adoption of electronic anesthetic records and video, phone, and chat consultations, an anesthesiologist can be integrated into the care team of any patient, anywhere in the world. This article reviews the benefits of adopting an electronic anesthetic record system, and the ways that practitioners can incorporate a virtual anesthesiologist into their care team.

Operating room team training using simulation: Hope or hype?

BACKGROUND

This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training.

METHOD

Two-wave survey study (immediate post-training survey 2010-2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests.

RESULTS

Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations.

CONCLUSIONS

Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.

Critical Incidents during Anesthesia and Early Post-Anesthetic Period: A Descriptive Cross-sectional Study

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.

Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation.

WHAT THIS ARTICLE TELLS US THAT IS NEW

Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief.

BACKGROUND

Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel.

METHODS

At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings.

RESULTS

During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers.

CONCLUSIONS

Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

Reporting system for critical incidents in cross-sectoral healthcare (CIRS-CS): pre-test of a reporting sheet and optimization of a reporting system

OBJECTIVE

Potential sources for errors or critical incidents in healthcare may arise not just within a healthcare facility, but also between healthcare facilities (e. g., in the communication between in- and outpatient care). This study aims to test the content validity of the reporting sheet and to optimize the cross-sectoral critical incident reporting system (CIRS-CS).

METHOD

The CIRS-CS was developed as a part of the project "solimed ePflegebericht" based on the expertise of the participating organizations as well as existing literature and existing reporting systems (e. g., the recommendations of the "German Coalition for Patient Safety"). In addition, a pre-test was conducted among the organizations participating in the "solimed ePflegebericht" to assess the content validity of the reporting sheet. Content validity was assessed using cognitive interviews (N=11) with health professionals. The interviews were conducted on the basis of predefined scenarios and probing questions.

RESULTS

The reporting sheet that was used for the pre-test consisted of 16 components such as reason for reporting/description of the problem, location of the patient at the time of reporting and suggested solution to the problem. The results of the pre-test indicated that participants found it challenging to relate to components such as In which type of healthcare service did the problem occur, What was the cause of the problem and Which factors contributed to the problem. For instance, some participants found it difficult to decide in which type of healthcare service (e. g., emergency care, routine care) the underlying problem occurred as this component could be reported from different perspectives, i. e. where the incident arose versus where the problem occurred. Thus, depending on the interpretation of this component, the participants questioned the feasibility since there was a lack of knowledge as to under which circumstances the incident arose.

CONCLUSION

The results of the pre-test of the CIRS-CS suggest that the description of the causes as well as potential solutions via the cross-sectoral reporting sheet is unfeasible and may be better approached with an interdisciplinary investigation team panel as part of the reporting system, in which the participating representatives are able to enter a structured dialogue based on the reported problems. Furthermore, the results indicate that investigation team panels enable an interprofessional exchange and may thus promote transparency between healthcare facilities. At this point, there is little research on the content validity of reporting sheets for cross-sectoral reporting systems. Hence, our results may contribute to the development of comprehensible and feasible cross-sectoral CIRS.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

Adverse Events in Anesthesia: An Integrative Review

PURPOSE

This study conducted an integrative review of the literature in a search for scientific evidence related to the occurrence of perioperative adverse events resulting from anesthesia.

DESIGN

Integrative review.

METHODS

The search was performed in the PubMed/MEDLINE, Virtual Health Library, Cumulative Index to Nursing and Allied Health, and Web of Science databases and portals, including studies published in Portuguese, English, or Spanish, from 1997 to 2017. The studies were supposed to assess adverse events associated exclusively with anesthesia care.

FINDINGS

We selected 21 studies. The main adverse events in anesthesia were respiratory, drug error, cardiology, and neurology. Most of the events were related to human errors, slips, and lapses that resulted in damage to the patient, such as permanent injuries or death.

CONCLUSIONS

Care planning, efficient communication, and teamwork are critical to prevent adverse events in anesthesia.

Clinical Audit on the Practice of Documentation at Preanesthetic Evaluation in a Specialized University Hospital

Background:

Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care.

Aim:

The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits.

Materials and Methods:

This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index.

Statistical Analysis:

Descriptive statistics was performed using SPSS version 20.

Results:

A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate.

Conclusions:

Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.

Medicolegal Claims against Anaesthetists: A 20 Year Study

A total of 222 medicolegal claims involving 160 anaesthetist members of Victoria's largest medical indemnity organization during the period 1980 to 1999 are reported, with 35% of anaesthetists having a claim. There were 49 claims in the fist decade and 173 in the second, with 84 related to dental injury being predominant. Other common causes of claims were awareness, epidural anaesthesia, coronial enquiries, nerve palsies, postoperative complications and circulatory arrest. Anaesthetists were joined with surgeons in 17 claims. The average delay between the incident and the resolution of the claim was 11 months for dental claims and 46 months for non-dental ones.

Incident reporting behaviours following the Francis report: A cross-sectional survey

RATIONALE, AIMS, AND OBJECTIVES

Previous studies have shown a lack of engagement in the reporting process. There is limited evidence about whether attitudes and behaviours of doctors in the UK towards incident reporting have changed following the events at Mid Staffordshire National Health Service Foundation Trust and the recommendations that followed. We conducted a relatively large survey of doctors, aiming to assess whether doctors recognised incidents and reported them accordingly, along with their behaviours towards reporting and their suggestions of how incident reporting may be improved.

METHODS

A cross-sectional survey of doctors was undertaken in 11 hospitals in the north of England. The participants (n = 581) were invited to take part in an electronic questionnaire. Demographics were obtained, and engagement with the incident reporting process was assessed, including an estimate of the number of incidents which were witnessed but not actually reported. Factors which influenced reporting behaviours were recorded. Free-text comments were encouraged. A mixed method analysis of the responses was performed.

RESULTS

Doctors do not appear to be engaging with the incident reporting process-in particular, junior doctors. The main reason given for not completing forms was not having enough time (38.2% of respondents), primarily due to the length and complexity of forms. Many doctors, 43.7%, witnessed more than 5 incidents, but only 13.3% of doctors submitted more than 5 reports. Free text comments revealed 4 themes which impact upon reporting behaviours: organisational issues, form structure, a culture of blame, and a lack of feedback. Several suggestions for improvement were made.

CONCLUSIONS

Little has changed in the attitudes and behaviours of doctors. Improving incident reporting form structure to make it more user-friendly and improving feedback may engage doctors and lead to an improved safety culture. The way the medical profession reports serious and other incidents still needs to be improved.

A rare case of nonresterilized reinforced ETT obstruction caused by a structural defect: A case report

RATIONALE

Various factors can cause ventilatory failure after endotracheal tube (ETT) intubation, which is associated with increased patient morbidity and mortality.

PATIENT CONCERNS

A 76-year-old woman who was diagnosed with a hemopericardium and suspicion of a major-vessel injury due to dislocation of the clavicular fracture fixation screw.

DIAGNOSIS

Non-resterilized reinforced ETT obstruction caused by a structural defect.

INTERVENTION

Endotracheal tube was exchanged.

OUTCOMES

The ventilator profile showed rapid improvement.

LESSONS

Anesthesiologists should consider that a non-resterilized reinforced ETT may be defective. An ETT defect can cause high PIP and ETT obstruction without kinking or foreign materials.

In Situ Operating Room-Based Simulation: A Review

OBJECTIVE

To systematically review the literature surrounding operating room-based in situ training in surgery.

METHODS

A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible.

RESULTS

The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics.

CONCLUSIONS

Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

Using multiclass classification to automate the identification of patient safety incident reports by type and severity

BACKGROUND

Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals.

METHODS

Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with "balanced" datasets (n_ _Type  = 2860, n_ _{SeverityLevel}  = 1160) from a state-wide incident reporting system. Testing was also undertaken with imbalanced "stratified" datasets (n_ _Type  = 6000, n_ _{SeverityLevel} =5950) from the state-wide system and an independent hospital reporting system. Classifier performance was evaluated using a confusion matrix, as well as F-score, precision and recall.

RESULTS

The most effective combination was a OvsO ensemble of binary SVM RBF classifiers with binary count feature extraction. For incident type, classifiers performed well on balanced and stratified datasets (F-score: 78.3, 73.9%), but were worse on independent datasets (68.5%). Reports about falls, medications, pressure injury, aggression and blood products were identified with high recall and precision. "Documentation" was the hardest type to identify. For severity level, F-score for severity assessment code (SAC) 1 (extreme risk) was 87.3 and 64% for SAC4 (low risk) on balanced data. With stratified data, high recall was achieved for SAC1 (82.8-84%) but precision was poor (6.8-11.2%). High risk incidents (SAC2) were confused with medium risk incidents (SAC3).

CONCLUSIONS

Binary classifier ensembles appear to be a feasible method for identifying incidents by type and severity level. Automated identification should enable safety problems to be detected and addressed in a more timely manner. Multi-label classifiers may be necessary for reports that relate to more than one incident type.

Simulation Testing for Selection of Critical Care Medicine Trainees. A Pilot Feasibility Study

RATIONALE

Selection of physicians into anesthesiology, intensive care, and emergency medicine training has traditionally relied on evaluation of curriculum vitae, letters of recommendation, and interviews, despite these methods being poor predictors of subsequent workplace performance.

OBJECTIVES

In this study, we evaluated the feasibility and face validity of incorporating assessment of nontechnical skills in simulation and personality traits into an existing junior doctor selection framework.

METHODS

Candidates short-listed for a critical care residency position were invited to participate in the study. On the interview day, consenting candidates participated in a simulation scenario and debriefing and completed a personality test (16 Personality Factor Questionnaire) and a survey. Timing of participants' progression through the stations and faculty staff numbers were evaluated. Nontechnical skills were evaluated and candidates ranked using the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). Nontechnical skills ranking and traditional selection method ranking were compared using the concordance correlation coefficient. Interrater reliability was assessed using the concordance correlation coefficient.

MEASUREMENTS AND MAIN RESULTS

Thirteen of 20 eligible participants consented to study inclusion. All participants completed the necessary stations without significant time delays. Eighteen staff members were required to conduct interviews, simulation, debriefing, and personality testing. Participants rated the simulation station to be acceptable, fair, and relevant and as providing an opportunity to demonstrate abilities. Personality testing was rated less fair, less relevant, and less acceptable, and as giving less opportunity to demonstrate abilities. Participants reported that simulation was equally as stressful as the interview, whereas personality testing was rated less stressful. Assessors rated both personality testing and simulation as acceptable and able to provide additional information about candidates. The Ottawa GRS showed moderate interrater concordance. There was moderate concordance between rankings based on traditional selection methods and Ottawa GRS rankings (ρ = 0.52; 95% confidence interval, -0.02 to 0.82; P = 0.06).

CONCLUSIONS

A multistation selection process involving interviews, simulation, and personality testing is feasible and has face validity. A potential barrier to adoption is the high number of faculty required to conduct the process.

A Cross-sectional Overview of the First 4,000 Incidents Reported to webAIRS, a De-identified Web-based Anaesthesia Incident Reporting System in Australia and New Zealand

webAIRS is a web-based de-identified anaesthesia incident reporting system, which was introduced in Australia and New Zealand in September 2009. By July 2016, 4,000 incident reports had been received. The incidents covered a wide range of patient age (<28 days to >90 years), American Society of Anesthesiologists physical status, and body mass index (<18.5 to >50 kg/m2). They occurred across a wide range of anaesthesia techniques and grade of anaesthesia provider, and over a wide range of anaesthetising locations and times of day. In a high proportion the outcome was not benign; about 26% of incidents were associated with patient harm and a further 4% with death. Incidents appeared to be an ever-present risk in anaesthetic practice, with extrapolated estimates exceeding 200 per week across Australia and New Zealand. Independent of outcomes, many anaesthesia incidents were associated with increased use of health resources. The four most common main categories of incident were Respiratory/Airway, Medication, Cardiovascular, and Medical Device/Equipment. Over 50% of incidents were considered preventable. The narratives accompanying each incident provide a rich source of information, which will be analysed in subsequent reports on particular incident types. The summary data in this initial overview are a sober reminder of the prevalence and unpredictability of anaesthesia incidents, and their potential morbidity and mortality. The data justify current efforts to better prevent and manage anaesthesia incidents in Australia and New Zealand, and identify areas in which increased resources or additional initiatives may be required.

Unit-based incident reporting and root cause analysis: variation at three hospital unit types

OBJECTIVES

To minimise adverse events in healthcare, various large-scale incident reporting and learning systems have been developed worldwide. Nevertheless, learning from patient safety incidents is going slowly. Local, unit-based reporting systems can help to get faster and more detailed insight into unit-specific safety issues. The aim of our study was to gain insight into types and causes of patient safety incidents in hospital units and to explore differences between unit types.

DESIGN

Prospective observational study.

SETTING

10 emergency medicine units, 10 internal medicine units and 10 general surgery units in 20 hospitals in the Netherlands participated. Patient safety incidents were reported by healthcare providers. Reports were analysed with root cause analysis. The results were compared between the 3 unit types.

RESULTS

A total of 2028 incidents were reported in an average reporting period of 8 weeks per unit. More than half had some consequences for patients, such as a prolonged hospital stay or longer waiting time, and a small number resulted in patient harm. Significant differences in incident types and causes were found between unit types. Emergency units reported more incidents related to collaboration, whereas surgical and internal medicine units reported more incidents related to medication use. The distribution of root causes of surgical and emergency medicine units showed more mutual similarities than those of internal medicine units.

CONCLUSIONS

Comparable incidents and causes have been found in all units, but there were also differences between units and unit types. Unit-based incident reporting gives specific information and therefore makes improvements easier. We conclude that unit-based incident reporting has an added value besides hospital-wide or national reporting systems that already exist in various countries.

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

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.

Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland

This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon dioxide monitoring have been updated.

Incident reporting by acute pain service at a tertiary care university hospital

BACKGROUND AND AIMS

Provision of effective and safe postoperative pain management is the principal responsibility of acute pain services (APSs). Continuous quality assurance is essential for high-quality patient care. We initiated anonymous reporting of critical incidents by APS to ensure continuous quality improvement and here present prospectively collected data on the reported incidents. Our objective was to analyze the frequency and nature of incidents and to see if any harm was caused to patients.

MATERIAL AND METHODS

Data were collected from January 1, 2012 to September 30, 2013. An incident related to pain management was defined as An incident that occurs in a patient receiving pain management supervised by APS, and causes or has the potential to cause harm or affects patient safety. A form was filled including incident type, personnel involved, any harm caused, and steps taken to rectify it. Frequencies and percentages were computed for categorical variables.

RESULTS

A total of 2042 patients were seen and 442 (21.64%) incidents reported during the study period, including documentation errors (136/31%), noncompliance with protocols (113/25.56%), wrong combination of drugs (56/12.66%), premature discontinuation (74/16.72%), prolonged delays in change of syringes (27/6.10%), loss to follow-up (19/4.29%), administration of contraindicated drugs (9/2.03%), catheter pull-outs (6/1.35%), and faulty equipment (2/0.45%). Steps were taken to rectify the errors accordingly. No harm was caused to any patient.

CONCLUSION

Reporting of untoward incidents and their regular analysis by APS is recommended to ensure high-quality patient care and to provide guidance in making teaching strategies and guidelines to improve patient safety.

Reporting critical incidents in a tertiary hospital: a historical cohort study of 110,310 procedures

Purpose

Investigation of adverse events associated with anesthetic procedures is a method of quality control that identifies topics to improve clinical care and patient safety. Most research to date has been based on closed claim registries and anonymous reports which have specific limitations. Therefore, to evaluate a hospital’s reporting system, the present study was designed to describe critical incidents that anesthesiologists voluntarily and non-anonymously reported through an anesthesia information management system.

Methods

This is a historical observational cohort study on patients (age > 18 yr) undergoing anesthetic procedures in a tertiary referral hospital. A 20-item list of complications, as developed by the Netherlands Society of Anesthesiologists, was prospectively completed for each procedure. All critical incidents registered in the anesthesia information management system were then reclassified into 95 different critical incidents in a reproducible way.

Results

There were 110,310 procedures performed in 65,985 patients, and after excluding 158 reports that did not depict a critical incident, 3,904 critical incidents in 3,807 (3.5%) anesthetic procedures remained. Technical difficulties with regional anesthesia (n = 445; 40 per 10,000 anesthetics; 95% confidence interval [CI], 36 to 44), hypotension (n = 432; 39 per 10,000 anesthetics; 95% CI, 35 to 43), and unexpected difficult intubation (n = 216; 20 per 10,000 anesthetics; 95% CI, 18 to 23) were the most frequently documented critical incidents.

Conclusion

Accurate measurement and monitoring of critical incidents is crucial for patient safety. Despite the risk of underreporting and probable misclassification of manual reporting systems, our results give a comprehensive overview on the occurrence of voluntarily reported anesthesia-related critical incidents. This overview can direct development of a new reporting system and preventive strategies to decrease the future occurrence of critical incidents.

Review of critical incidents in a university department of anaesthesia

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

Technological advances in perioperative monitoring: Current concepts and clinical perspectives

Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.

A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting

Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification. Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.

Quality and safety in pediatric anesthesia

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer

INTRODUCTION

The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events.

METHODS

We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined.

RESULTS

A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was $309 066, compared to $291 000 for all physician specialties.

CONCLUSIONS

The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.

Effects of divided attention and operating room noise on perception of pulse oximeter pitch changes: a laboratory study

BACKGROUND

Anesthesiology requires performing visually oriented procedures while monitoring auditory information about a patient's vital signs. A concern in operating room environments is the amount of competing information and the effects that divided attention has on patient monitoring, such as detecting auditory changes in arterial oxygen saturation via pulse oximetry.

METHODS

The authors measured the impact of visual attentional load and auditory background noise on the ability of anesthesia residents to monitor the pulse oximeter auditory display in a laboratory setting. Accuracies and response times were recorded reflecting anesthesiologists' abilities to detect changes in oxygen saturation across three levels of visual attention in quiet and with noise.

RESULTS

Results show that visual attentional load substantially affects the ability to detect changes in oxygen saturation concentrations conveyed by auditory cues signaling 99 and 98% saturation. These effects are compounded by auditory noise, up to a 17% decline in performance. These deficits are seen in the ability to accurately detect a change in oxygen saturation and in speed of response.

CONCLUSIONS

Most anesthesia accidents are initiated by small errors that cascade into serious events. Lack of monitor vigilance and inattention are two of the more commonly cited factors. Reducing such errors is thus a priority for improving patient safety. Specifically, efforts to reduce distractors and decrease background noise should be considered during induction and emergence, periods of especially high risk, when anesthesiologists has to attend to many tasks and are thus susceptible to error.

With how many users should you test a medical infusion pump? Sampling strategies for usability tests on high-risk systems

Usability testing is recognized as an effective means to improve the usability of medical devices and prevent harm for patients and users. Effectiveness of problem discovery in usability testing strongly depends on size and representativeness of the sample. We introduce the late control strategy, which is to continuously monitor effectiveness of a study towards a preset target. A statistical model, the LNB(zt) model, is presented, supporting the late control strategy. We report on a case study, where a prototype medical infusion pump underwent a usability test with 34 users. On the data obtained in this study, the LNB(zt) model is evaluated and compared against earlier prediction models. The LNB(zt) model fits the data much better than previously suggested approaches and improves prediction. We measure the effectiveness of problem identification, and observe that it is lower than is suggested by much of the literature. Larger sample sizes seem to be in order. In addition, the testing process showed high levels of uncertainty and volatility at small to moderate sample sizes, partly due to users' individual differences. In reaction, we propose the idiosyncrasy score as a means to obtain representative samples. Statistical programs are provided to assist practitioners and researchers in applying the late control strategy.