Library guides: Safety & quality: Articles &amp; publications

Guide index

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Publications

Top 10 Patient Safety Concerns for Healthcare Organisations (2018 report)

ECRI Institute provides open access to the Executive Brief

Safety of Anaesthesia (Mortality) report

ANZCA publishes triennial reports on anaesthesia mortality in Australia and New Zealand. They can be found in the Safety of Anaesthesia section of the ANZCA Anaesthetic incident reporting webpage.

ANZCA Bulletin - Safety and quality articles

Safety and quality [Internet]. ANZCA Bulletin; 29(2); 2020: 44-45.

Safety and quality. [Internet]. ANZCA Bulletin; 29(1); 2020: 20-25.

Safety and quality. [Internet]. ANZCA Bulletin; 28(4); 2019: 26-27.

Safety and quality. [Internet]. ANZCA Bulletin; 28(3); 2019: 44-47.

ANZCA E-Newsletter - Safety and quality articles

Archived links are provided below to articles of interest in the quality and safety section of recent editions of the ANZCA E-Newsletter:

Codeine in children – new safety warnings [web archive]

A coroner’s report into an airway related death in Scotland (September 2013)

Hydroxyethyl-starch (Voluven) [web archive]

Perioperative Mortality in New Zealand

Fifth report of the Perioperative Mortality Review Committee ;(the POMRC). Report to the Health Quality & Safety Commission New Zealand (June 2016)

This report presents information on perioperative mortality in New Zealand during 2009–2013 for two new clinical areas: 30-day mortality following operations and procedures under general anaesthesia and day-of-the week mortality. As part of the POMRC’s continued surveillance of perioperative mortality over time, rates for a number of clinical areas and procedures included in previous reports are presented here for 2009–2014.

Recent articles of interest

Last updated: 11 August 2023

Wittenmeier E, Schmidtmann I, Heese P, et al. Early warning for SpO2 decrease by the oxygen reserve index in neonates and small infants [published online ahead of print, 2023 Aug 8]. Paediatr Anaesth. 2023;10.1111/pan.14743. Keywords: anesthesia; hypoxia; infants; oximetry; safety.
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Abstract
Introduction: Continuously assessing the oxygenation levels of patients to detect and prevent hypoxemia can be advantageous for safe anesthesia, especially in neonates and small infants. The oxygen reserve index (ORI) is a new parameter that can assess oxygenation through a relationship with arterial oxygen partial pressure (PaO2 ). The aim of this study was to examine whether the ORI provides a clinically relevant warning time for an impending SpO2 (pulse oximetry hemoglobin saturation) reduction in neonates and small infants.

Methods: ORI and SpO2 were measured continuously in infants aged <2 years during general anesthesia. The warning time and sensitivity of different ORI alarms for detecting impending SpO2 decrease were calculated. Subsequently, the agreement of the ORI and PaO2 with blood gas analyses was assessed.

Results: The ORI of 100 small infants and neonates with a median age of 9 months (min-max, 0-21 months) and weight of 8.35 kg (min-max, 2-13 kg) were measured. For the ORI/PaO2 correlation, 54 blood gas analyses were performed. The warning time and sensitivity of the preset ORI alarm during the entire duration of anesthesia were 84 s (25th-75th percentile, 56-102 s) and 55% (95% CI 52%-58%), and those during anesthesia induction were 63 s (40-82 s) and 56% (44%-68%), respectively. The positive predictive value of the preset ORI alarm were 18% (95% CI 17%-20%; entire duration of anesthesia) and 27% (95% CI 21%-35%; during anesthesia induction). The agreement of PaO2 intervals with the ORI intervals was poor, with a kappa of 0.00 (95% CI = [-0.18; 0.18]). The weight (p = .0129) and height (p = .0376) of the infants and neonates were correlated to the correct classification of the PaO2 interval with the ORI interval.

Conclusions: The ORI provided an early warning time for detecting an impending SpO2 decrease in small infants and neonates in the defined interval in this study. However, the sensitivity of ORI to forewarn a SpO2 decrease and the agreement of the ORI with PaO2 intervals in this real-life scenario were too poor to recommend the ORI as a useful early warning indicator for this age group.
Olesnicky BL, Trumper R, Chen V, Culwick MD. The use of sugammadex in critical events in anaesthesia: A retrospective review of the webAIRS database [epub ahead of print, 2022 Feb 17]. Anaesth Intensive Care. Keywords: Sugammadex; anaphylaxis: diagnosis and treatment; factors causing prolonged neuromuscular blockade; muscle relaxants
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Sugammadex has been used for more than ten years in Australia and New Zealand and has been implicated as an effective treatment, and in some cases a potential cause, of a critical incident. We aimed to identify and analyse critical incidents involving sugammadex reported to webAIRS, a de-identified voluntary online critical incident reporting system in Australia and New Zealand. We identified 116 incidents where the reporter implicated sugammadex as either a cause (23 cases) or a treatment (93 cases) during anaesthesia. There were 17 incidents suggestive of sugammadex anaphylaxis, although not all were confirmed by skin testing. There were six incidents when bradycardia was temporally related to sugammadex administration, although it was not possible to exclude other causes or contributory factors. There were nine incidents in which sugammadex was used to reverse aminosteroid-related neuromuscular blockade successfully in a 'can't intubate, can't oxygenate' (CICO) situation, and a further 67 incidents in which sugammadex was used to reverse aminosteroid neuromuscular blockade as part of the management of other critical incidents. While sugammadex was used during the management of 16 cases of anaphylaxis, there was no clear indication that this altered the course of the anaphylaxis in any of the cases. These reports indicate that sugammadex can be a potential trigger for anaphylaxis and that its use may be associated with the development of significant bradycardia. However, it is not possible to estimate or even speculate on the incidence of these sugammadex-related incidents on the basis of voluntary reporting to a database such as webAIRS. The reports also indicate that sugammadex has been used successfully to reverse residual or deep aminosteroid neuromuscular blockade in critical incident situations and to help rescue CICO scenarios. These findings provide further support for ensuring the ready availability of sugammadex wherever aminosteroid muscle relaxants are used.
Yu CV et al. Noise in the operating room during induction of anesthesia: impact of a quality improvement initiative [epub ahead of print, 2022 Jan 10]. Can J Anaesth. Keywords: Distraction; Noise; Occupational health; Patient satisfaction; Quality improvement
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Purpose: Noise in the operating room (OR) is common and associated with negative effects on anesthesiologists, surgeons, and patient outcomes. Induction of anesthesia is among the loudest perioperative periods. Despite its critical nature, there is little data on noise levels during induction, associated patient and anesthesiologist satisfaction, and the effects of noise reduction strategies.

Methods: We conducted a two-part prospective interventional quality improvement project on the care of adult patients receiving general anesthesia for elective noncardiac surgery. For part A, we measured average and peak noise (dB[A]) levels during anesthesia induction in N = 100 cases and administered a satisfaction questionnaire to anesthesiologists. We then applied a multidisciplinary educational program to OR personnel on active noise reduction strategies and subsequently collected data during N = 109 cases in a post-intervention phase. For part B, we administered satisfaction questionnaires to N = 100 patients pre- vs postintervention, respectively.

Results: Median [interquartile range] noise levels throughout induction were 66.0 [62.5-68.6] dB(A) preintervention vs 63.5 [60.1-65.4] dB[A] post-intervention (Hodges-Lehmann estimator of the difference, - 2.7 dB[A]; 95% confidence interval [CI], - 4.0 to - 1.5; P < 0.001). Peak noise levels during induction were 87.3 [84.0-90.5] dB(A) preintervention and 86.2 [81.8-89.3] dB(A) postintervention (Hodges-Lehmann estimator of the difference, - 1.8 dB[A]; 95% CI, - 3.3 to - 0.3; P = 0.02). Noise-related anesthesiologist satisfaction postintervention was significantly improved in multiple domains, including assessment of noise having distracted anesthesiologists. Patient satisfaction was high pre-intervention and did not significantly improve further.

Conclusion: In this quality improvement project, average noise levels during induction of anesthesia, anesthesiologist satisfaction, and anesthesiologists' perceived ability to perform were improved following a multidisciplinary educational program on noise reduction in the OR.

Study registration: www.ClinicalTrials.gov (NCT04204785); registered 19 December 2019.
Gibbs NM, Culwick MD, Endlich Y, Merry AF. A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Anaesth Intensive Care. 2021;49(6):422-42 Keywords: Anaesthesia; anaesthetic mortality; complications; equipment; quality assurance; safety and incident monitoring.
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Abstract
This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.

Biccard BM, Green-Thompson L. Socially accountable anaesthesia: matching human resources with community need for safe care. Anaesthesia. 2018;73(3):271-274.

Arriaga AF, Sweeney RE, Clapp JT, et al.Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.Anesthesiology. 2019;130(6):1039-1048.

Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care. Academic Medicine : Journal of the Association of American Medical Colleges. 2020;95(1):59-68.

Gelb, A. W., et al. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesthesia & Analgesia. 2018; 126(6): 2047-2055.

Harper, N. J. N., et al. Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6). British Journal of Anaesthesia. 2018 [epub ahead of print]; available online 21 May 2018.

Schumacher DJ, Frohna JG. Patient safety and quality improvement: A ‘CLER’ time to move beyond peripheral participation. Med Educ Online. 2016;21: 31993

Wallace S, Myles PS, Zeps N, Zalcberg JR.Serious adverse event reporting in investigator-initiated clinical trials.Med J Aust. 2016;204(6):231-233.

Guglielminotti J, Wong CA, Landau R, Li G. Temporal trends in anesthesia-related adverse events in cesarean deliveries, New York state, 2003-2012. Anesthesiology. 2015;123(5):1013-1023.

Leslie K, Myles PS, Kasza J, Forbes A, Peyton PJ, Chan MT, et al. Nitrous oxide and serious long-term morbidity and mortality in the evaluation of nitrous oxide in the gas mixture for anaesthesia (enigma)-ii trial. Anesthesiology. 2015;123(6):1267-1280.

Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):25-34.

Patel S, Loveridge R. Obstetric neuraxial drug administration errors: A quantitative and qualitative analytical review. Anesth Analg. 2015;121(6):1570-1577.

Ramly EP, Larentzakis A, Bohnen JD, Mavros M, Chang Y, Lee J, et al. The financial impact of intraoperative adverse events in abdominal surgery. Surgery. 2015;158(5):1382-1388.

Tscholl DW, Weiss M, Kolbe M, Staender S, Seifert B, Landert D, et al. An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams. Anesth Analg. 2015;121(4):948-956.

Safety & quality: Articles & publications

Find full-text: Lookup any journal article by DOI or PMID

Publications

Recent articles of interest