Critical incident reporting in an anaesthetic department quality assurance programme

Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review

BACKGROUND

Intravenous (IV) medication is commonly administered and closely associated with patient safety. Although nurses dedicate considerable time and effort to rate the control of IV medications, many medication errors have been linked to the wrong rate of IV medication. Further, there is a lack of comprehensive studies examining the literature on rate control of IV medications. This study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing and synthesizing the existing literature.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley and PRISMA-ScR. Overall, four databases-PubMed, Web of Science, EMBASE, and CINAHL-were employed to search for studies published in English before January 2023. We also manually searched reference lists, related journals, and Google Scholar.

RESULTS

A total of 1211 studies were retrieved from the database searches and 23 studies were identified from manual searches, after which 22 studies were selected for the analysis. Among the nine project or experiment studies, two interventions were effective in decreasing errors related to rate control of IV medications. One of them was prospective, continuous incident reporting followed by prevention strategies, and the other encompassed six interventions to mitigate interruptions in medication verification and administration. Facilitators and barriers related to rate control of IV medications were classified as human, design, and system-related contributing factors. The sub-categories of human factors were classified as knowledge deficit, performance deficit, and incorrect dosage or infusion rate. The sub-category of design factor was device. The system-related contributing factors were classified as frequent interruptions and distractions, training, assignment or placement of healthcare providers (HCPs) or inexperienced personnel, policies and procedures, and communication systems between HCPs.

CONCLUSIONS

Further research is needed to develop effective interventions to improve IV rate control. Considering the rapid growth of technology in medical settings, interventions and policy changes regarding education and the work environment are necessary. Additionally, each key group such as HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices should perform its role and cooperate for appropriate IV rate control within a structured system.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

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%.

Critical incidents during anesthesia in a developing country: A retrospective audit

Background:

Critical incidents occur inadvertently where ever humans work. Reporting these incidents and near misses is important in learning and prevention of future mishaps. The aim of our study was to identify the incidence, outcome and potential risk factors leading to critical incidents during anaesthesia in a tertiary care teaching hospital and attempt to suggest preventive strategies that will improve patient care.

Materials and Methods:

A retrospective audit of all anaesthesia charts for documented critical incidents over a 12 month period was carried out. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anaesthetists were noted. The data collected was analysed using the SPSS software.

Results:

Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. More females suffered critical incidents. Patients in the 4^th and 5^th decades of life were noted to be more susceptible. Airway and cardiovascular incidents were the commonest. Anaesthetists with less than 6 years experience were involved in more mishaps.

Conclusion:

We conclude that airway mishaps and cardiovascular instability were the commonest incidents especially in the hands of junior anaesthetists.

The frequency and nature of drug administration error during anaesthesia in a Chinese hospital

BACKGROUND

Throughout the world, drug administration error remains a known and significant threat to patients undergoing anaesthesia. Estimates of the extent of the problem vary, but few are based on large prospectively collected datasets. Furthermore, little is known about whether differences in work culture are important in error rates.

METHODS

A prospective incident monitoring study was conducted at a large tertiary hospital in China to estimate the frequency of drug administration error during anaesthesia. Anaesthetists were asked to return a study form anonymously for every anaesthetic, indicating whether or not a drug administration error had occurred, including incident details if affirmative.

RESULTS

From 24,380 anaesthetics, 16,496 study forms were returned (67.7% response rate), reporting 179 errors. The frequency (95% confidence interval) of drug administration error was 0.73% (0.63% to 0.85%) based on total study anaesthetics and 1.09% (0.93% to 1.26%) based on total forms returned. The largest categories of error were omissions (27%), incorrect doses (23%) and substitutions (20%). Errors resulted in prolonged stay in recovery for 21 patients, transfer to the ICU for five and one case each of haemorrhagic shock and asthmatic attack. More respondents who were not fully rested reported inattention as a contributing factor to error (21%) than those who were fully rested (7%, P = 0.04).

CONCLUSION

Our results are comparable with other international prospective estimates indicating that drug administration error is of concern in China as elsewhere. These results will form a baseline from which to detect the effects of countermeasures.

On the Value of Nonremovable Reminders for Behavior Modification

The authors examined the effectiveness of a novel behavior modification method for dysfunctional and impulsive habits, based on nonremovable reminders (NrRs). NrRs were implemented by having participants wear nonremovable wristbands designated to constantly remind them of their resolution to quit the targeted habit (nail-biting). Participants were 80 nail-biters who resolved to quit. The NrR approach was contrasted with an aversion-based behavioral modification technique. Recovery was assessed after 3 and 6 weeks of treatment and in a 5-month follow-up. The NrR method was associated with lower drop-out rate and was as successful as the aversion-based method altogether. When considering only non-dropouts, the aversion-based method was more effective. This suggests that the use of constantly present reminders broadens the target population that can benefit from reminders in the course of behavior modification.

Drug administration errors: a prospective survey from three South African teaching hospitals

This prospective study was undertaken to determine the incidence of drug administration errors by anaesthetists at three tertiary South African hospitals. Hospitals A and C treat adults predominantly, whereas Hospital B is a paediatric hospital. Anaesthetists completed an anonymous study form for every anaesthetic performed over a six-month period. They were asked to indicate whether or not an error or near-miss had occurred and if so, the details thereof. A total of 30,412 anaesthetics were administered during the study period. The response rate and combined incidence of errors and near-misses was as follows: Hospital A 48.8% (1:320), B 81.3% (1:252) and C 48.1% (1:250). The overall response rate was 53% and the combined incidence was 1:274. Neither the experience of the anaesthetist nor emergency surgery influenced whether an error occurred or not. Most errors occurred during the maintenance phase of anaesthesia. The most common errors were those of substitution. At the paediatric hospital, incorrect dose was as frequent an error as substitution. Of all errors, 36.9% were due to drug ampoule misidentification; of these the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported. Despite an increasing awareness of the problem together with suggestions in the literature to reduce the incidence, drug administration errors remain fairly common in South Africa. Failure to institute suggested solutions will continue to compromise patient safety.

Evaluation of critical incidents in general surgery

Background

The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility.

Methods

All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted.

Results

Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47·7 per cent to be execution failures and 45·9 per cent knowledge-based errors. The distribution of medical errors was 12·9 per cent diagnostic, 46·0 per cent treatment, 17·3 per cent preventive and 23·7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21·6 per cent.

Conclusion

This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.

Anaesthetic rooms: luxury or necessity?

Induction of anaesthesia in an anaesthetic room has been a feature of UK practice since 1860. In 2002 only 4% of UK anaesthetic departments routinely anaesthetized all patients in theatre (Broomhead and Jones, 2002). In most other countries, induction takes place on the operating table in theatre without any apparent disadvantage to the patient. £30 million has been spent equipping anaesthetic rooms in the UK since 1994 in order to comply with minimum standards of monitoring (Association of Anaesthetists of Great Britain and Ireland (AAGBI), 1994). There has been considerable debate over the past 15 years about the use of anaesthetic rooms particularly given the increasing costs of monitoring equipment. This article explores the use of anaesthetic rooms in modern clinical practice.

[Adverse events and adverse event reporting systems]

Knowledge about the incidence of errors in anaesthesia and intensive care is only rudimentary but it appears justified to assume that errors occur much more often than we all expect. One reason is most likely the complexity of our work. Errors may alter our patients' health and healing process, imply financial and legal personal and institutional threats and may reduce health workers' performances. The article summarizes several methods to identify errors within a health care system and strengthens the importance of error analysis to reduce its incidence. Results of an analysis should be published if they are of general interest.

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

BACKGROUND

The purpose of the present study was to measure the incidence and type of incidents that occurred in relation to anaesthesia and surgery during a 1-year period in six Danish hospitals. Furthermore, we wanted to identify risk factors for incidents, as well as risk factors for incidents being deemed critical.

METHODS

A four-page questionnaire describing patient data, type of anaesthesia and surgery, and occurrence of incidents was filled in for all anaesthesias in the period, and subsequently processed. The incident reporting form incorporated 59 predefined adverse events. The occurrence of one or more of these events described the incident. When the reporting anaesthetist deemed that an incident had harmed the patient, that incident was defined as critical.

RESULTS

A total of 64,312 anaesthesias were reported, and in 7754 of them one or more incidents occurred. A total of 8510 incidents occurred, 4077 of them were solely related to the anaesthetic procedure, 3702 described events related to physiological alterations in the patient (physiological incidents). Three hundred and twenty-three of the incidents were deemed critical. High ASA score, high age, abdominal surgery, urgent surgery, and complex anaesthetic procedure were significant risk factors for physiological incidents and critical incidents. We could not identify a simple subset of adverse events that could adequately be used to describe the critical incidents. However, complex incidents, i.e. incidents involving more than one adverse event, were more likely to be deemed critical than simple incidents.

CONCLUSION

The incidence of incidents was 12.1%, and the incidence of critical incidents was 0.5%. Incidents were more likely to be deemed critical in patients with an ASA score of III and above undergoing urgent surgery.

Anonymes Meldesystem kritischer Ereignisse in der Anästhesie

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

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.

Evidence-based strategies for preventing drug administration errors during anaesthesia

We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.

Evaluation of two new ecological interface approaches for the anesthesia workplace

OBJECTIVE

Currently, vital parameters are commonly displayed as trends along a timeline. However, clinical decisions are more often based upon concepts, such as the depth of anesthesia, that are derived by combining parameter relationships and additional context information. The current displays do not visualize such concepts and therefore do not optimally support the decision process. A new display should present an ecological interface (EI). The principle of EI design is to visualize all of the information necessary for decision making in one single display.

METHODS

In the first approach, we developed an EI that visualizes 35 relevant parameters for anesthesia monitoring. All of the parameters are generated by an anesthesia software simulator. Sixteen anesthetists had to administer two simulated general anesthetics: in one setting working only with the simulator's monitors ("Sim Only"), and in another setting working with the simulator's monitors in combination with the EI ("Combi1"). During each experiment, one unexpected critical incident (either blood loss or a cuff leakage) had to be identified. The control and monitoring behavior was analyzed by recording the subjects' eye movements and think-aloud protocol. With the help of the eye-tracking results, we re-designed the EI. The new EI was then tested with no eye tracking ("Combi2") on eight anesthetists under analogous conditions as in "Combi1."

RESULTS

Cuff leakage was identified significantly quicker in "Combi1" (7 of 8 cases; time (T): 65 s +/- 73 s) than in "SimOnly" (6 of 8 cases; T: 222 s +/- 187 s). Blood loss was identified in 5 of 8 cases (T: 215 s +/- 76 s) in "Combi1" as quickly as in "SimOnly" (all cases; T: 217 s +/- 72 s). In "Combi1," the EI was used as the main source of information (in 43 +/- 19% of time) and was frequently favored when identifying an evolving critical incident. In "Combi2," cuff leakage was identified in 7 of 8 cases (T: 70 s +/- 111 s) as quickly as in "Combi1." Blood loss was identified significantly quicker in all cases (T: 147 s +/- 62 s) in "Combi2" than in "Combi1" and in "SimOnly."

CONCLUSION

The results have shown that appropriately designed EIs may improve the anesthetist's decision making and focus attention on specific problems. Now, the findings have to be tested in future studies by widening the scope using other simulated scenarios and being closer to reality under real conditions in the OR. Eye tracking proved to be a useful method to analyze the anesthetists' decision making and appropriately re-design interfaces.

Equipment problems during anaesthesia--are they a quality problem?

BACKGROUND

Anaesthesia equipment problems may contribute to anaesthetic morbidity and mortality. The magnitude and pattern of these problems are not established. We wanted to analyse the frequency, type and severity of equipment-related problems in our department, and if additional efforts to improve safety were needed.

METHODS

The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis. The data include intraoperative problems and their severity. When a problem occurs, the anaesthetist responsible for the case writes a short description of the event on the anaesthetic chart. From all recorded cases of general and regional anaesthesia, we selected cases recorded with anaesthetic 'equipment/technical problems'. These charts were retrieved from departmental archives for analysis.

RESULTS

From 83 154 anaesthetics, we found the frequency of anaesthetic equipment problems to be 0.05% during regional anaesthesia, and 0.23% during general anaesthesia. One-third of problems involved the anaesthesia machine, and in a quarter, human error was involved. No patient died and none suffered any lasting morbidity.

CONCLUSION

The rate of equipment problems was low, and most often of low severity. Aside from improvements in routines for preoperative equipment checks, no specific strategies for problem reduction could be suggested. The incidence of equipment problems is not a good quality indicator because of the low rate of occurrence. However, recorded equipment problems may be useful for improving quality, by analysing causative factors, and suggesting preventative strategies.

Professional monitoring and critical incident reporting using personal digital assistants

OBJECTIVE

To assess the practicality of using personal digital assistants (PDAs) for the collection of logbook data, procedural performance data and critical incident reports in anaesthetic trainees.

DESIGN

Pilot study.

SETTING

Two tertiary referral centres (in Victoria and New Zealand) and a large district hospital in Queensland.

PARTICIPANTS

Six accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their ANZCA training supervisors.

INTERVENTIONS

Registrars and supervisors underwent initial training for one hour, and supervisors were provided with ongoing support.

MAIN OUTCOME MEASURES

Reliable use of the program, average time for data entry and number of procedures logged.

RESULTS

ANZCA trainees reliably enter data into PDAs. The data can be transferred to a central database, where they can be remotely analysed before results are fed back to trainees.

CONCLUSIONS

This technology can be used to monitor professional performance in ANZCA trainees.

Transfer of facility clients to inpatient psychiatry: eight criteria to consider

The transfer of residential clients with mental retardation to inpatient psychiatric care units (IPUs) presents several areas in which clinical and administrative incidents can occur. Incident review management can be applied as an effective administrative tool to improve the transfer of such clients by considering the needs of clients in the context of their caregivers and the goals of the IPU. This article introduces eight criteria to facilitate and evaluate the transfer of such clients and help reduce the rate of incidents.

Inpatient psychiatry incident review management: Part I. Special issues

Incident review (IR) is a process for achieving a better understanding of problems related to the health and safety of clients and the integrity of healthcare facilities. The purpose of IR is to identify and document adverse incidents through fact-finding. Incidents may vary in both type and levels of seriousness. Through careful documentation, investigation, and committee review, patterns of healthcare delivery can be discerned. The goal of IR is the development of systemic performance improvements in healthcare delivery, which may serve to anticipate and deter the recurrence of similar incidents. IR ensures that the quality and performance of healthcare delivery in the facility continue to be improved by both administrative and clinical staff members. This article examines IR in the context of the inpatient psychiatry unit.

[Cardiorespiratory arrest in the intensive care unit: theoretical considerations on factors related with iatrogenic events]

The attendance of Cardiopulmonary Resuscitation (CPR) demands rapidity, efficiency, scientific knowledge and technical ability. Still, an adequate infra structure is vital as well as the accomplishment of an harmonic and synchronized work and team performance, in order to promote the patient's backup. Iatrogenic factors related to attendance of CPR in the Intensive Care Unit may be due to professional inexperience, insufficient staff and problems with material or equipments. Thus, the team must be prepared to assist the patient efficiently, as resuscitation should restore the life process and not prolong the death process.

Analysis of the French health ministry's national register of incidents involving medical devices in anaesthesia and intensive care

This study details all incidents involving medical devices used in anaesthesia and intensive care reported to the relevant authorities in France in 1998. There were 1004 reports during that year. Incidents were classified as serious (harmful to patients) in 11% of cases; death resulted in 2% of cases. Equipment for ventilation and infusion, and monitors of all kinds, accounted for most of the reports, representing 37%, 30% and 12%, respectively, of all reports. The leading causes of failure varied according to the category of device. User errors, quality control problems during production of the device and design faults were the three main causes. The problems identified during the study period enabled the faulty medical devices to be improved in 12-44% of cases. We conclude that post-marketing vigilance is a useful way of improving the quality of medical devices.

Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?

BACKGROUND

Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems.

OBJECTIVES

To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems.

METHODS

As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data.

RESULTS

During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction).

CONCLUSION

Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting.

Challenges to effective incident review management: administrative and clinical factors

Incident review (IR) is a process for achieving a better understanding of problems related to the health and safety of clients and the integrity of healthcare facilities. The IR process ensures that the quality and the performance of care in a facility continue to be maintained and improved over time. Because of the practical realities of administrative and clinical care issues, the process of implementing IR and related interventions is often challenging. This paper examines the IR process and the barriers that affect and impede it.

Ergonomic evaluation of an ecological interface and a profilogram display for hemodynamic monitoring

OBJECTIVE

Comprehensive monitoring of the patient state and subsequent decision making is an essential part of the task of an anaesthetist. The physicians' decision making process is based upon a concept of partly abstract physiologic parameters such as depth of anaesthesia or contractility. This concept is derived from the measured parameters given on todays' trend displays in addition to context information available for the anaesthetist. We investigated two alternative approaches of display design for hemodynamic monitoring: 1) integrated displays based on ecological interface design, and 2) profilogram displays based on intelligent alarms.

METHOD

To evaluate differences in decision making, the two displays and a trend display were compared in an experimental set-up with computer simulated vital parameter curves. From a start state with random parameter deviations from the ideal state, subjects had to achieve the ideal circulatory performance as fast as possible by manipulating vasomotor tone, heart rate, blood volume and contractility. To analyse subjects' decision making process, eye-tracking, event-logging, and the method of think aloud protocols were used. Twenty anaesthesiologists performed 113 experiments (approximately 2 with each display).

RESULTS

The anaesthetists failed to achieve the task in 37% using the trend display, in 19% using the profilogram display, and in 13% using the ecological interface. Hence, a safer task solution was possible with the ecological interface and the profilogram display but at the expense of various performance parameters such as higher trial time, more interactions with the simulated system, and more frequent eye movements. In contrast to the trend display and the profilogram display, where anaesthetists were mainly focussed on controlling the left atrial pressure, such an behaviour was less observed with the ecological interface.

CONCLUSION

Our results have shown that subjects came to more effective solutions with the traditional trend display. The main reason for this result may be their years of experience with this kind of display type. Regarding safe and goal-intended decision finding, the results are encouraging for further experiments with redesigned ecological displays. But these displays ought to have smoother changes with respect to the traditional trend displays. Furthermore, new experiments have to be performed under real or fairly real (e.g. together with an anaesthesia simulator) conditions to underline the positive results for ecological interfaces.

Quality control of postoperative acute pain service

To establish an effective method of continuous quality control of acute pain service, a retrospective study on incident reporting during postoperative analgesia period was conducted. Incidents were reported and analyzed in 1507 patients who received epidural postoperative analgesia, and the results of satisfaction of pain relief was compared with those of incident analysis. In this study, an incident was defined as any factor that might or had affected patient's safety during analgesia period. Our results showed that 1203 incidents were reported in 641 of 1507 patients, of which 122 incidents were critical. 78.3% of all incidents were detected by acute pain service stuff. The most common incidents included complications, insufficient analgesia and problems with delivery circuits. Human factors were involved in 28.9% of the incidents, most being associated with technical failure due to unskillfulness, poor communications between APS stuff and patients and lack of cooperation with surgeons and nurses. The general satisfaction rate of the patients was 90.8%. There was a very significant difference between the satisfaction of the patients who suffered from incidents and who did not (P < 0.001). It is concluded that incidents affect the satisfaction of the patients who received postoperative pain relief. Incident reporting is a more effective method for quality control of acute pain service.

Compliance with an incident report scheme in anaesthesia

Voluntary anonymous reporting of incidents which occur during anaesthesia is a mechanism for obtaining information about such problems. Our objective was to estimate with reporting such incidents. For 3 months, alongside the incident report form, another form, which had to be completed for every patient, was used. This form listed a series of defined events which could occur intra-operatively. Compliance with the incident reports was estimated by comparing the data obtained from the two sets of forms. Overall compliance was only about 30%. There were differences in compliance for different events. Compliance was high with more serious events and poor in the case of common events, or when successful recovery had occurred. In order to improve compliance, incident report forms should be available on each anaesthetic machine and staff should be made more aware of the fact that reportable incidents are not limited to events which harmed the patient, but also include those which could have affected patient safety.

A critical incident study of general practice trainees in their basic general practice term

OBJECTIVE

To obtain information on the experiences of general practice (GP) trainees during their first general practice (GP) attachment.

DESIGN

Critical incident technique--a qualitative analysis of open-ended interviews about incidents which describe competent or poor professional practice.

SUBJECTS

Thirty-nine Western Australian doctors from the Royal Australian College of General Practitioners' (RACGP) Family Medicine Program who were completing their first six months of general practice in 1992.

RESULTS

Doctors reported 180 critical incidents, of which just over 50% involved problems (and sometimes successes) with: difficult patients; paediatrics; the doctor-patient relationship; counselling skills; obstetrics and gynaecology; relationships with other health professionals and practice staff; and cardiovascular disorders. The major skills associated with both positive and negative critical incidents were: the interpersonal skills of rapport and listening; the diagnostic skills of thorough clinical assessment and the appropriate use of investigations; and the management skills of knowing when and how to obtain help from supervisors, hospitals and specialists. Doctors reported high levels of anxiety over difficult management decisions and feelings of guilt over missed diagnoses and inadequate management.

CONCLUSION

The initial GP term is a crucial transition period in the development of the future general practitioner. An analysis of commonly recurring positive and negative critical incidents can be used by the RACGP Training Program to accelerate the learning process of doctors in vocational training and has implications for the planning of undergraduate curricula.