Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet

An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.

Medical students and informed consent-response to "Consent for Teaching"

Nil.

A prospective observational study on the effect of emboli exposure on cerebral autoregulation in cardiac surgery requiring cardiopulmonary bypass

Objective:

Cerebrovascular autoregulation impairment has been associated with stroke risk in cardiac surgery. We hypothesized that greater arterial emboli exposure in open-chamber surgery might promote dysautoreguation.

Methods:

Forty patients underwent closed or open-chamber surgery. Transcranial Doppler detected emboli and measured bilateral middle cerebral artery flow velocities. Cerebral autoregulation was assessed by averaging the mean velocity index (“Mx,” a continuous moving correlation between cerebral blood flow velocity and mean arterial pressure) over 30 min before and after aortic cross-clamp removal.

Results:

Median (interquartile range) emboli counts were 775 (415, 1211) and 2664 (793, 3734) in the closed-chamber and open-chamber groups. Most appeared after the removal of the aortic cross-clamp (open-chamber 1631 (606, 2296)), (closed-chamber 229 (142, 384)), with emphasis on the right hemisphere (open-chamber: 826 (371, 1622)), (closed-chamber 181 (66, 276)). Linear mixed model analyses of mean velocity index change showed no significant overall effect of group (0.08, 95% CI: −0.04, 0.21; p = 0.19) or side (0.01, 95% CI: −0.03, 0.05; p = 0.74). There was an interaction between group and side ( p = 0.001), manifesting as a greater increase in mean velocity index in the right hemisphere in the open than the closed group (mean difference: 0.15, 95% CI: 0.02, 0.27; p = 0.03).

Conclusions:

Overall, change in mean velocity index before and after cross-clamp removal did not differ between groups. However, most emboli entered the right cerebral hemisphere where this change was significantly greater in the open-chamber group, suggesting a possible association between embolic exposure and dysautoregulation.

Clinicians' experiences of inquiries following mental health related homicide: a qualitative study

OBJECTIVES

This aim of this qualitative study was to explore the experiences of clinicians involved with inquiries into the mental health care of patients who were perpetrators of homicide in New Zealand.

METHODS

Our purposive sample comprised ten clinicians working in New Zealand district health board mental health services. These clinicians were individually interviewed. Interviews were audio-recorded, transcribed and thematically analysed. The coding framework was checked and peer reviewed by an independent researcher.

RESULTS

Five themes were identified: the inquiry process; emotional burden; impact on team dynamics; changes to individual clinical practice; and perceptions of inquiries being influenced by organisational culture. Clinicians involved with inquiries reported significant anxiety and disrupted multidisciplinary team dynamics. Some participants found inquiries led to changes to their clinical practice and perceived that a punitive organisational culture limited learning.

CONCLUSIONS

Clinicians perceived inquiries as threatening, anxiety provoking and primarily concerned with protecting organisational interests. Communication of the inquiry process and ensuring inquiry findings are disseminated may enhance clinicians' experiences of inquiries and facilitate their participation and their reflection on changes to clinical practice that could contribute to improving services. Support for clinicians and multidisciplinary teams should be emphasised by the commissioning agency.

Hospital accreditation processes in Saudi Arabia: a thematic analysis of hospital staff experiences

Background

Hospital accreditation by an international organisation can play an important role in health quality and safety. However, little is known about how managers and front-line employees experience and perceive the effects of accreditation. Their views could inform quality improvement processes and procedures.

Objective

To explore perceptions of employees at the managerial level on the Joint Commission International (JCI) accreditation process and its impact on quality of patient care in Saudi Arabian JCI-accredited hospitals.

Methods

We undertook a qualitative study using semi-structured interviews to explore the perspectives of senior staff from three accredited public hospitals in Saudi Arabia. Interviews were transcribed prior to thematic analysis.

Results

Twenty managers participated in the interviews. The following inter-related themes emerged concerning the JCI accreditation process and its impact on quality of patient care: drivers for the change; the plan for the change; the process of the change; maintaining changes post-accreditation and patients’ issues. Participants were positive in their accounts of: drivers for the change; planning for the change needed to achieve accreditation and managing patients’ issues. However, participants reported less favourably on: the process of the change; and maintaining changes post-accreditation.

Conclusion

The planning stage was perceived as the easiest component of JCI accreditation. Implementing and maintaining changes post-accreditation that demonstrably promote patient safety and quality of care was perceived as more difficult. When planning for accreditation, institutions need to incorporate strategies to ensure that improvements to care continue beyond the accreditation period.

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

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.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use.

Background

In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices.

Methods

An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS.

Results

A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%).

Conclusions

While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.

Reporting of Clinical Outcomes After Endovascular Aortic Aneurysm Repair: A Systematic Review

BACKGROUND

Endovascular aneurysm repair (EVAR) is an established treatment for many patients with infra-renal abdominal aortic aneurysm (AAA). Reporting standards were published in 2002 to ensure consistent measurement and reporting of outcomes following EVAR. We aimed to assess the range of clinical outcomes reported after EVAR and whether recent studies adhere to established reporting standards.

METHODS

We searched MEDLINE and Embase from January 2014 until December 2018, using terms for 'EVAR' and 'AAA'. We included prospective studies and randomised controlled trials which reported clinical outcomes of elective infra-renal AAA repair. Data on clinical outcome reporting were extracted and compared with established reporting standards.

RESULTS

84 studies were included. Technical success was reported in 49 (58.3%) studies, but only defined in 40 (47.6%), with 22 distinct definitions. Clinical success was reported and defined in 19 (22.6%) studies. Aneurysm rupture was reported in 27 (32.1%) studies and death from rupture in 11 (13.1%) studies. All-cause and aneurysm-related mortality were reported in 72 (85.7%) and 52 (61.9%) studies, respectively. Endoleak type I (n = 61, 72.6%) and II (n = 52, 61.9%) were more commonly reported than type III (n = 45, 53.6%) or IV (n = 13, 15.5%). Complications and mortality were reported by a mean of 18 (21.4%) and 42 (50%) studies, respectively.

CONCLUSIONS

A wide variety of clinical outcomes were reported following EVAR. Few studies adhered to reporting guidelines. We recommend modification of reporting standards to reflect advances in endovascular technology and creation of a core outcome set for EVAR.

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Māori and 2047/51,921 (3.9%) for non-Māori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Māori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Māori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Māori patients had worse outcomes than non-Māori.

Communication and team function affect patient outcomes in anaesthesia: getting the message across

A study in this edition of the Journal has added to data showing that failures in communication in the operating room contribute to patient harm. These data support the view that multidisciplinary teamwork and communication training should be part of the continuous professional development of all members of the perioperative team. Achieving change will require efforts to win the hearts and minds of all concerned, but these data also support an expectation that engagement in initiatives and techniques to enhance communication and teamwork should not be optional.

A prospective observational study of emboli exposure in open versus closed chamber cardiac surgery

OBJECTIVE

Exposure to cerebral emboli is ubiquitous and may be harmful in cardiac surgery utilizing cardiopulmonary bypass. This was a prospective observational study aiming to compare emboli exposure in closed-chamber with open-chamber cardiac surgery, distinguish particulate from gaseous emboli and examine cerebral laterality in distribution.

METHODS

Forty patients underwent either closed-chamber procedures (n = 20) or open-chamber procedures (n = 20). Emboli (gaseous and solid) were detected using transcranial Doppler in both middle cerebral arteries in two monitoring phases: 1, initiation of bypass to the removal of the aortic cross-clamp; and 2, removal of aortic cross-clamp to 20 minutes after venous decannulation.

RESULTS

Total (median (interquartile range)) emboli counts (both phases) were 898 (499-1366) and 2617 (1007-5847) in closed-chamber and open-chamber surgeries, respectively. The vast majority were gaseous; median 794 (closed-chamber surgery) and 2240 (open-chamber surgery). When normalized for duration, there was no difference between emboli exposures in closed-chamber and open-chamber surgery in phase 1: 6.8 (3.6-15.2) versus 6.4 (2.0-18.1) emboli per minute, respectively. In phase 2, closed-chamber surgery cases were exposed to markedly fewer emboli than open-chamber surgery cases: 9.6 (5.1-14.9) versus 43.3 (19.7-60.3) emboli per minute, respectively. More emboli (total) passed into the right cerebral circulation: 985 (397-2422) right versus 376 (198-769) left.

CONCLUSIONS

Patients undergoing open-chamber surgery are exposed to considerably higher numbers of cerebral arterial emboli after removal of the aortic cross-clamp than those undergoing closed-chamber surgery, and more emboli enter the right middle cerebral artery than the left. These results may help inform the evaluation of the pathophysiological impact of emboli exposure.

The conduct of inquiries: a qualitative study of the perspectives of panel members who investigate mental health related homicide

BACKGROUND

Inquiries into mental health related homicides may be held to identify failures in care and areas for improvement, accountability and to enhance public confidence. However, inquiries do not always achieve these aims.

AIM

The aim of this study was to explore the perspectives of members of inquiry panels who conduct inquiries into mental health related homicides in order to identify elements that would constitute a good inquiry.

METHODS

We selected a sample of inquiry panel members comprising 15 senior clinicians, legal experts and consumer advisors. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis.

RESULTS

Participants raised concerns related to: (1) orientation of the panel to the inquiry task; (2) clarity of the process; and (3) impact of the inquiry. Most participants recognised that inquiries require a focus on mental health systems and sensitivity to families and clinicians. They reported difficulties in clarifying purposes, attending to cultural aspects of the case, having a clear method tailored to the mental health context, formulating recommendations and disseminating findings.

CONCLUSIONS

Our participants perceived a number of weaknesses in the process by which inquiries into mental health related homicides had been conducted, and recommendations formulated and implemented. There is an opportunity to address these and thereby potentially improve the effectiveness and value of inquiries.

Checklists for image-guided interventions: a systematic review

OBJECTIVES

Safety checklists have improved safety in patients undergoing surgery. Checklists have been designed specifically for use in image-guided interventions. This systematic review aimed to identify checklists designed for use in radiological interventions and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use.

METHODS

OVID, MEDLINE, CENTRAL and CINAHL were searched using terms for "interventional radiology" and "checklist". Studies were included if they described pre-procedural checklist use in vascular/body interventional radiology (IR), paediatric IR or interventional neuro-radiology (INR). Data on checklist design, implementation and outcomes were extracted.

RESULTS

Sixteen studies were included. Most studies (n = 14, 87.5%) focused on body IR. Two studies (12.5%) measured perioperative outcome after checklist implementation, but both had important limitations. Checklist use varied between 54 and 100% and completion of items on the checklists varied between 28 and 100%. Several barriers to checklist use were identified, including a lack of leadership and education and cultural challenges unique to radiology.

CONCLUSIONS

We found few reports of the use of checklists in image-guided interventions. Approaches to checklist implementation varied, and several barriers to their use were identified. Evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in radiological procedures.

ADVANCES IN KNOWLEDGE

There are few reports of the use of checklists in radiological interventions, those identified reported significant barriers to the effective use of checklists.

General Anaesthesia Shifts the Murine Circadian Clock in a Time-Dependant Fashion

Following general anaesthesia (GA), patients frequently experience sleep disruption and fatigue, which has been hypothesized to result at least in part by GA affecting the circadian clock. Here, we provide the first comprehensive time-dependent analysis of the effects of the commonly administered inhalational anaesthetic, isoflurane, on the murine circadian clock, by analysing its effects on (a) behavioural locomotor rhythms and (b) PER2::LUC expression in the suprachiasmatic nuclei (SCN) of the mouse brain. Behavioural phase shifts elicited by exposure of mice (n = 80) to six hours of GA (2% isoflurane) were determined by recording wheel-running rhythms in constant conditions (DD). Phase shifts in PER2::LUC expression were determined by recording bioluminescence in organotypic SCN slices (n = 38) prior to and following GA exposure (2% isoflurane). Full phase response curves for the effects of GA on behaviour and PER2::LUC rhythms were constructed, which show that the effects of GA are highly time-dependent. Shifts in SCN PER2 expression were much larger than those of behaviour (c. 0.7 h behaviour vs. 7.5 h PER2::LUC). We discuss the implications of this work for understanding how GA affects the clock, and how it may inform the development of chronotherapeutic strategies to reduce GA-induced phase-shifting in patients.

Families of victims of homicide: qualitative study of their experiences with mental health inquiries

BACKGROUND

Investigations may be undertaken into mental healthcare related homicides to ascertain if lessons can be learned to prevent the chance of recurrence. Families of victims are variably involved in serious incident reviews. Their perspectives on the inquiry process have rarely been studied.

AIMS

To explore the experiences of investigative processes from the perspectives of family members of homicide victims killed by a mental health patient to better inform the process of conducting inquiries.

METHOD

The study design was informed by interpretive description methodology. Semi-structured interviews were conducted with five families whose loved one had been killed by a mental health patient and where there had been a subsequent inquiry process in New Zealand. Data were analysed using an inductive approach.

RESULTS

Families in this study felt excluded, marginalised and disempowered by mental health inquires. The data highlight these families' perspectives, particularly on the importance of a clear process of inquiry, and of actions by healthcare providers that indicate restorative intent.

CONCLUSIONS

Families in this study were united in reporting that they felt excluded from mental health inquiries. We suggest that the inclusion of families' perspectives should be a key consideration in the conduct of mental health inquiries. There may be benefit from inquiries that communicate a clear process of investigation that reflects restorative intent, acknowledges victims, provides appropriate apologies and gives families opportunities to contribute.

Sustaining multidisciplinary team training in New Zealand hospitals: a qualitative study of a national simulation-based initiative

AIM

Healthcare is delivered by teams, but the training of healthcare staff is commonly undertaken in professional silos. This study investigated local perspectives on the sustainability of NetworkZ, a New Zealand national simulation-based multi-disciplinary operating room team training programme.

METHOD

Local course instructors and managers were invited to participate in semi-structured interviews. Diffusion of innovations theory was utilised to frame deductive thematic analysis of interview data.

RESULTS

Twenty-seven people participated. Interviewees described valuing NetworkZ for its multi-disciplinary orientation, in-situ delivery, scenario realism, relevance to teamwork and communication and potential for generalisability to other settings. Interviewees also identified NetworkZ as generating improvements in teamwork and crisis management. NetworkZ was described as complex, due to multidisciplinary participation and the multiple roles and skillsets of instructors needed to run simulations smoothly, making the programme resource intensive to deliver.

CONCLUSION

NetworkZ is appreciated as a valuable and unique programme for developing important teamwork and communication skills. Its sustainability is dependent on adequate resourcing and funding.

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings

OBJECTIVE

To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care.

DESIGN

Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting.

SETTING

Cardiac surgical unit in New Zealand.

PARTICIPANTS

Culturally diverse patients in hospital undergoing heart surgery.

MAIN OUTCOMES

A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort.

RESULTS

Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment.

CONCLUSIONS

These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

Mental Health Inquiries in the Case of Homicide

We aimed to identify features of New Zealand government-commissioned inquiries into the provision of mental health services after homicides committed by service users. The analysis of five reports from 1992 to 2016 identified similarities across reports, which included documenting a process; responding to a set terms of reference; detailing a case chronology, risk assessment, team and system issues; making recommendations and giving opportunities to clinicians to respond to adverse comments. Differences included selecting key informants and acknowledging limitations of scope. The inquiries did not specify a means to disseminate findings to stakeholders and follow up recommendations. Unrealised opportunities include attention to relationships between stakeholders and ways to support learning from inquiries. There is no standardised approach to conducting statutory inquiries into mental health services following a homicide. This limits the value of such inquiries for learning and service improvement. We recommend a standardised framework be developed to guide inquiries.

Mental Health Inquiries in the Case of Homicide

We aimed to identify features of New Zealand government-commissioned inquiries into the provision of mental health services after homicides committed by service users. The analysis of five reports from 1992 to 2016 identified similarities across reports, which included documenting a process; responding to a set terms of reference; detailing a case chronology, risk assessment, team and system issues; making recommendations and giving opportunities to clinicians to respond to adverse comments. Differences included selecting key informants and acknowledging limitations of scope. The inquiries did not specify a means to disseminate findings to stakeholders and follow up recommendations. Unrealised opportunities include attention to relationships between stakeholders and ways to support learning from inquiries. There is no standardised approach to conducting statutory inquiries into mental health services following a homicide. This limits the value of such inquiries for learning and service improvement. We recommend a standardised framework be developed to guide inquiries.

Aspiration during anaesthesia in the first 4000 incidents reported to webAIRS

The first 4000 reports to the webAIRS anaesthesia incident reporting database were used to evaluate pulmonary aspiration in patients undergoing procedures under general anaesthesia or sedation. Demographic data, predisposing factors, outcome and potential preventative measures were evaluated. In these reports, 121 cases of aspiration were identified. Aspirated substances included gastric contents, bile type fluids, blood and solids; 60 (49.6%) patients were admitted to the intensive care unit/high dependency unit, and 43 (35.5%) required mechanical ventilation. Aspiration was associated with significant harm in >50% of reports, and eight (6.6%) patients died. Factors associated with a risk ratio of aspiration >1.5 and outside the 95% confidence interval for no event included: age >80 years, emergency procedure, procedure undertaken in freestanding day unit or gastroenterology department, procedure undertaken between 1800 and 2200 hours and endoscopy procedures. Only 11 (9%) cases appeared to be inadequately fasted, and 77 (64%) were definitely fasted. In the remaining 33 (27%), fasting was not mentioned. In 18 (14.9%) cases, aspiration occurred in the presence of cricoid pressure. Potential measures to prevent aspiration included using a cuffed endotracheal tube rather than a laryngeal mask airway in cases at high risk of aspiration and being made more aware of potential risk factors by improvements in team communication. Aspiration continues to be an important complication of anaesthesia, and one that can be difficult to predict and to prevent.

The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial

Background

Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Māori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces.

Methods

We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental “champions”. Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle.

Discussion

If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000407291. Registered on 21 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3402-8) contains supplementary material, which is available to authorized users.

Practice patterns and perceptions of Australian and New Zealand anaesthetists towards perioperative oxygen therapy

We conducted a survey of Australian and New Zealand anaesthetists to determine self-reported practice of perioperative oxygen administration and to quantify perceptions regarding the perceived benefits and risks resulting from liberal oxygen therapy delivered in a manner consistent with the current World Health Organization guidelines. In addition, we sought feedback on the acceptability of several proposed clinical trial designs aiming to assess the overall effect of liberal and restricted perioperative oxygen regimens on patient outcomes. We developed a 23-question electronic survey that was emailed to 972 randomly selected Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. We received responses from 282 of 972 invitees (response rate 29%). The majority of survey participants indicated that they routinely titrate inspired oxygen to a level they feel is safe (164/282, 58%) or minimise oxygen administration (82/282, 29%), while 5% of respondents indicated that they aim to maximise oxygen administration. The mean value for targeted intraoperative fraction inspired oxygen (FiO2) was 0.41 (standard deviation 0.12). Of the survey respondents, 2/282 (0.7%) indicated they believe that routine intra- and postoperative administration of ≥80% oxygen reduces the risk of surgical site infection. Well-designed and conducted randomised trials on this topic may help to better direct clinicians' choices. A high level of willingness to participate (80% of responses) in a study designed to investigate the impact of differing approaches to perioperative oxygen administration suggests that recruitment is likely to be feasible in a future study.

Measurement of patient-reported outcomes after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Patient-reported outcome (PRO) measures (PROMs) are increasingly used as endpoints in surgical trials. PROs need to be consistently measured and reported to accurately evaluate surgical care. Laparoscopic cholecystectomy (LC) is a commonly performed procedure which may be evaluated by PROs. We aimed to evaluate the frequency and consistency of PRO measurement and reporting after LC.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting PROs of LC, between 2013 and 2016. Data on the measurement and reporting of PROs were extracted.

RESULTS

A total of 281 studies were evaluated. Forty-five unique multi-item questionnaires were identified, most of which were used in single studies (n = 35). One hundred and ten unique rating scales were used to assess 358 PROs. The visual analogue scale was used to assess 24 different PROs, 17 of which were only reported in single studies. Details about the type of rating scale used were not given for 72 scales. Three hundred and twenty-three PROs were reported in 162 studies without details given about the scale or questionnaire used to evaluate them.

CONCLUSIONS

Considerable variation was identified in the choice of PROs reported after LC, and in how they were measured. PRO measurement for LC is focused on short-term outcomes, such as post-operative pain, rather than longer-term outcomes. Consideration should be given towards the development of a core outcome set for LC which incorporates PROs.

Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: a qualitative study

OBJECTIVE

To capture and better understand patients' experience during their healthcare journey from hospital admission to discharge, and to identify patient suggestions for improvement.

DESIGN

Prospective, exploratory, qualitative study. Patients were asked to complete an unstructured written diary expressed in their own words, recording negative and positive experiences or anything else they considered noteworthy.

PARTICIPANTS AND SETTING

Patients undergoing vascular surgery in a metropolitan hospital.

PRIMARY OUTCOME MEASURES

Complete diary transcripts underwent a general inductive thematic analysis, and opportunities to improve the experience of care were identified and collated.

RESULTS

We recruited 113 patients in order to collect 80 completed diaries from 78 participants (a participant response rate of 69%), recording patients' experiences of their hospital-stay journey. Participating patients were a median (range) age of 69 (21-99) years and diaries contained a median (range) of 197 (26-1672) words each. Study participants with a tertiary education wrote more in their diaries than those without-a median (range) of 353.5 (48-1672) vs 163 (26-1599) words, respectively (Mann-Whitney U test, p=0.001). Three primary and eight secondary themes emerged from analysis of diary transcripts-primary themes being: (1) communication as central to care; (2) importance of feeling cared for and (3) environmental factors shaping experiences. In the great majority, participants reported positive experiences on the hospital ward. However, a set of 12 patient suggestions for improvement were identified, the majority of which could be addressed with little cost but result in substantial improvements in patient experience. Half of the 12 suggestions for improvement fell into primary theme 1, concerning opportunities to improve communication between healthcare providers and patients.

CONCLUSIONS

Unstructured diaries completed in a patient's own words appear to be an effective and simple approach to capture the hospital-stay experience from the patient's own perspective, and to identify opportunities for improvement.

Examining reliability of WHOBARS: a tool to measure the quality of administration of WHO surgical safety checklist using generalisability theory with surgical teams from three New Zealand hospitals

OBJECTIVES

To extend reliability of WHO Behaviourally Anchored Rating Scale (WHOBARS) to measure the quality of WHO Surgical Safety Checklist administration using generalisability theory. In this context, extending reliability refers to establishing generalisability of the tool scores across populations of teams and raters by accounting for the relevant sources of measurement errors.

DESIGN

Cross-sectional random effect measurement design assessing surgical teams by the five items on the three Checklist phases, and at three sites by two trained raters simultaneously.

SETTING

The data were collected in three tertiary hospitals in Auckland, New Zealand in 2016 and included 60 teams observed in 60 different cases with an equal number of teams (n=20) per site. All elective and acute cases (adults and children) involving surgery under general anaesthesia during normal working hours were eligible.

PARTICIPANTS

The study included 243 surgical staff members, 138 (50.12%) women.

MAIN OUTCOME MEASURE

Absolute generalisability coefficient that accounts for variance due to items, phases, sites and raters for the WHOBARS measure of the quality of WHO Surgical Safety Checklist administration.

RESULTS

The WHOBARS in its present form has demonstrated good generalisability of scores across teams and raters (G absolute=0.83). The largest source of measurement error was the interaction between the surgical team and the rater, accounting for 16.7% (95% CI 16.4 to 16.9) of the total variance in the data. Removing any items from the WHOBARS led to a decrease in the overall reliability of the instrument.

CONCLUSIONS

Assessing checklist administration quality is important for promoting improvement in its use, and WHOBARS offers a reliable approach for doing this.

Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration.

DESIGN

Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews.

PARTICIPANTS

OR staff in three New Zealand hospitals.

OUTCOME MEASURES

Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration.

RESULTS

Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone.

CONCLUSIONS

The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.

Is Conventional Bypass for Coronary Artery Bypass Graft Surgery a Misnomer?

Although recent trials comparing on vs. off-pump revascularization techniques describe cardiopulmonary bypass (CPB) as "conventional," inadequate description and evaluation of how CPB is managed often exist in the peer-reviewed literature. We identify and subsequently describe regional and center-level differences in the techniques and equipment used for conducting CPB in the setting of coronary artery bypass grafting (CABG) surgery. We accessed prospectively collected data among isolated CABG procedures submitted to either the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) or Perfusion Measures and outcomes (PERForm) Registry between January 1, 2014, and December 31, 2015. Variation in equipment and management practices reflecting key areas of CPB is described across 47 centers (ANZCPR: 9; PERForm: 38). We report average usage (categorical data) or median values (continuous data) at the center-level, along with the minimum and maximum across centers. Three thousand five hundred sixty-two patients were identified in the ANZCPR and 8,450 in PERForm. Substantial variation in equipment usage and CPB management practices existed (within and across registries). Open venous reservoirs were commonly used across both registries (nearly 100%), as were "all-but-cannula" biopassive surface coatings (>90%), whereas roller pumps were more commonly used in ANZCPR (ANZCPR: 85% vs. PERForm: 64%). ANZCPR participants had 640 mL absolute higher net prime volumes, attributed in part to higher total prime volume (1,462 mL vs. 1,217 mL) and lower adoption of retrograde autologous priming (20% vs. 81%). ANZCPR participants had higher nadir hematocrit on CPB (27 vs. 25). Minimal absolute differences existed in exposure to high arterial outflow temperatures (36.6°C vs. 37.0°C). We report substantial center and registry differences in both the type of equipment used and CPB management strategies. These findings suggest that the term "conventional bypass" may not adequately reflect real-world experiences. Instead of using this term, authors should provide key details of the CPB practices used in their patients.

Medical students, sensitive examinations and patient consent: a qualitative review

AIM

We set out to explore the question, what ethical challenges do medical students identify when asked to perform or observe a sensitive examination, given a historical background relevant to this context.

METHOD

Thematic analysis of 21 Ethics Reports from 9 female and 12 male students.

RESULTS

Overall 14 students undertook a sensitive examination without the patient's consent; three did not carry out a sensitive examination because of a lack of consent; and two students (or their senior colleagues) gained the patient's written consent for the student to undertake the examination. One patient refused the student's request for consent to perform a digital rectal examination; and in the final case, verbal consent was given by the patient for the student to observe a bimanual examination only. Three interrelated core themes arose from thematic analysis of the research question: systemic constraints on getting consent; internal conflicts of interest; and, power and hierarchy.

CONCLUSIONS

A number of senior medical students at our institution disclosed observing or performing sensitive examinations on patients without the patients' knowledge or consent.

Reporting of complications after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016.

RESULTS

In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%).

CONCLUSION

Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

The New Zealand Surgical Site Infection Improvement (SSII) Programme: a national quality improvement programme reducing orthopaedic surgical site infections

AIMS

The New Zealand Surgical Site Infection Improvement (SSII) Programme was established in 2013 to reduce the incidence of surgical site infections (SSI) in publicly funded hip and knee arthroplasties in New Zealand hospitals.

METHODS

The programme pursued a three-pronged strategy: 1. Surveillance of SSI with a nationwide system 2. Promotion of consistent adherence to evidence-based practices proven to reduce SSI 3. Monitoring and publicly reporting changed practice and outcome data.

RESULTS

Between quarter 3 2013 and quarter 4 2016 there has been a nationwide increase in compliance with all process measures: correct timing for antibiotic prophylaxis; use of the recommended antibiotic in the recommended dose and alcohol-based skin antisepsis. The SSI rate in hip and knee arthroplasties has shown a significant improvement. The nationwide median rate has fallen to 0.91% since June 2015, compared with 1.36% during the baseline period of April 2013 to March 2014 (p<0.01). This equates to approximately 55 fewer infections between August 2015 and June 2017, savings of NZD$2.2 million in avoided treatment and avoided disability-adjusted life years (DALYs) of NZD$5 million.

CONCLUSIONS

The introduction of a nationwide SSI reduction programme for hip and knee arthroplasties resulted in an increase in compliance across the country with best practice that was associated with a reduction in incidence of SSI since June 2015 from the baseline period of April 2013 to March 2014, sustained to June 2017.

The incidence of hyperthermia during craniotomy

There is evidence that even mild hyperthermia may exacerbate brain injury. There seem reasonable grounds for considering patients undergoing craniotomy as at risk for brain injury. A retrospective observational study was undertaken to measure the incidence of mild hyperthermia in craniotomy cases in which the patient was initially normothermic. Auckland City Hospital's database of electronic anaesthetic records was searched for adult patients who were normothermic (≤37°C) prior to undergoing craniotomy procedures. For each case, demographic data, intraoperative naso- or oropharyngeal temperature measurements, and paracetamol use were extracted. We identified the proportion of patients whose temperature rose to exceed normal (>37°C) and subdivided that group into the proportion in whom the temperature rose to ≥38°C. Two thousand, nine hundred and thirty-five craniotomy cases began their operations while normothermic and had adequate temperature data collected. There were 984 (33.5%) cases that had at least one temperature reading >37°C, for a mean (standard deviation [SD]) time of 66.0 (64.6) minutes, and 49 (1.7%) cases that had at least one reading ≥38°C for a mean (SD) time of 40.4 (38.1) minutes. The majority (77.8%) who became mildly hyperthermic remained so at the end of the procedure. New mild hyperthermia occurs commonly during craniotomy. In view of the compelling evidence of potential harm arising from mild hyperthermia in brain injury, these findings suggest an opportunity for practice improvement in the anaesthetic management of craniotomy patients. Reasonable steps should be taken by anaesthetists to avoid intraoperative hyperthermia of any degree.

Ward calls not so scary for medical students after interprofessional simulation course: a mixed-methods cohort evaluation study

Background

An interprofessional simulation ‘ward call’ course—WardSim—was designed and implemented for medical, pharmacy and nursing students. We evaluated this intervention and also explored students’ experiences and ideas of both the course and of ward calls.

Methods

We used a mixed-methods cohort study design including survey and focus groups. Descriptive statistical analysis and general purpose thematic analysis were undertaken.

Results

Survey respondents who participated in WardSim subsequently attended more ward calls and took a more active role than the control cohort, with 34% of the intervention cohort attending ward calls under indirect supervision, compared with 15% from the control cohort (P=0.004). Focus group participants indicated that the situation they were most anxious about facing in the future was attending a ward call. They reported that their collective experiences on WardSim alleviated such anxiety because it offered them experiential learning that they could then apply in real-life situations. They said they had learnt how to work effectively with other team members, to take on a leadership role, to make differential diagnoses under pressure and to effectively communicate and seek help.

Conclusions

An interprofessional, simulated ward call course increased medical students’ sense of preparedness for and participation in ward calls in the next calendar year.

A framework of comfort for practice: An integrative review identifying the multiple influences on patients' experience of comfort in healthcare settings

Purpose

Comfort is central to patient experience but the concept of comfort is poorly defined. This review aims to develop a framework representing patients' complex perspective of comfort to inform practice and guide initiatives to improve the quality of healthcare.

Data sources

CINAHL, MEDLINE Complete, PsycINFO and Google Scholar (November 2016); reference lists of included publications.

Study selection

Qualitative and theoretical studies advancing knowledge about the concept of comfort in healthcare settings. Studies rated for methodological quality and relevance to patients' perspectives.

Data extraction

Data on design, methods, features of the concept of comfort, influences on patients' comfort. Data were systematically coded and categorized using Framework method.

Results of data synthesis

Sixty-two studies (14 theoretical and 48 qualitative) were included. Qualitative studies explored patient and staff perspectives in varying healthcare settings including hospice, emergency departments, paediatric, medical and surgical wards and residential care for the elderly. From patients' perspective, comfort is multidimensional, characterized by relief from physical discomfort and feeling positive and strengthened in one's ability to cope with the challenges of illness, injury and disability. Different factors are important to different individuals. We identified 10 areas of influence within four interrelated levels: patients' use of self-comforting strategies; family presence; staff actions and behaviours; and environmental factors.

Conclusion

Our data provide new insights into the nature of comfort as a highly personal and contextual experience influenced in different individuals by different factors that we have classified into a framework to guide practice and quality improvement initiatives.

What are we injecting with our drugs?

In preparation for a case, an anaesthetist opened a 20 ml glass vial of propofol and aspirated the propofol into a syringe via a blunt drawing-up needle. Increased resistance was felt with aspiration. On inspection, a shard of glass was found at the tip of the drawing-up needle. The shard was presumed to be from the propofol ampoule, and to have fallen into the solution upon snapping open its glass tip. This illustrative case raises the issue of contamination of drugs by particles introduced during the drawing-up process. It also highlights the possibility that during the drawing-up process, intravenous drugs may become contaminated not just with particles, but with microorganisms on the surface of the particles. In this article, we discuss relevant recent research of the implications of this type of drug contamination. We draw attention to the need for meticulous care in drawing up and administering intravenous drugs during anaesthesia, particularly propofol.