Last updated: 9 January 2024
Alhawsawi A, Greenfield D. Implementing co-production to enhance patient safety: the introduction of the Patient Safety Consent tool, an example of a simple local solution to a common challenge. Int J Qual Health Care. Epub December 28, 2023.Abstract
Zero harm is one of the priorities that all healthcare systems are aspiring for. However, more than two decades after 'To Err is Human' report, many systems are struggling to identify or implement strategies to achieve this important goal [1]. One of the very powerful, yet underutilized strategies towards transforming patient safety and achieving Zero Harm is 'co-production' [2]. Co-production of health is defined as 'the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations' [2]. Simply put, co-production means that patients contribute alongside professionals to the provision of health services [3]. While we know the importance and potential value of co-production, many health systems are underutilizing the approach. Actions to effectively implement and sustain changes to service provision to use co-production are elusive [4]. To realize improvements, a key requirement for health professionals is addressing the question: how can we implement and sustain co-production in efficient, effective ways?
Pattullo GG, Culwick MD, Endlich Y, MacPherson RD. Hypercarbia and high-flow nasal oxygen use during anaesthesia - risking a failure to thrive? [epub ahead of print, 2023 Oct 11]. Anaesth Intensive Care. 2023;310057X231198257.
Keywords: Airway; anaesthesia; complications; medicine; monitoring; physiology; respiratory.
Abstract
Prevention of arterial oxygen desaturation during anaesthesia with high-flow nasal oxygen (HFNO) has gained greater acceptance for a widening range of procedures. However, during HFNO use there remains the potential for development of significant anaesthesia-associated apnoea or hypoventilation and the possibility of hypercarbia, with harmful cardiovascular or neurological sequelae. The aim of this study was to determine whether any HFNO-related hypercarbia adverse incidents had been reported on webAIRS, an online database of adverse anaesthesia-related incidents. Two relevant reports were identified of complications due to marked hypercarbia during HFNO use to maintain oxygenation. In both reports, HFNO and total intravenous anaesthesia were used during endoscopic procedures through the upper airway. In both, the extent of hypoventilation went undetected during HFNO use. An ensuing cardiac arrest was reported in one report, ascribed to acute hypercarbia-induced exacerbation of the patient's pre-existing pulmonary hypertension. In the other report, hypercarbia led to a prolonged duration of decreased level of consciousness post procedure, requiring ventilatory support. During the search, an additional 11 reports of postoperative hypercarbia-associated sedation were identified, unrelated to HFNO. In these additional reports an extended duration of severe acute hypercarbia led to sedation or loss of consciousness, consistent with the known effects of hypercarbia on consciousness. These 13 reports highlight the potential dangers of unrecognised and untreated hypercarbia, even if adequate oxygenation is maintained.
Mistry MM, Endlich Y. Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS. Anaesth Intensive Care. 2023 Nov;51(6):408-421.
Keywords: Safety and incident monitoring; blockades; central neuraxial anaesthesia; error; non-technical skills; paediatrics; quality assurance; regional anaesthesia.
Abstract
Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.
Bright MR, Endlich Y, King ZD, White LD, Concha Blamey SI, Culwick MD. Adult perioperative cardiac arrest: An overview of 684 cases reported to webAIRS. Anaesth Intensive Care. 2023 Nov;51(6):375-390.
Keywords: Perioperative; cardiac arrest; complications; mortality.
Abstract
There were 684 perioperative cardiac arrests reported to webAIRS between September 2009 and March 2022. The majority involved patients older than 60 years, classified as American Society of Anesthesiologists Physical Status 3 to 5, undergoing an emergency or major procedure. The most common precipitants included airway events, cardiovascular events, massive blood loss. medication issues, and sepsis. The highest mortality rate was 54% of the 46 cases in the miscellaneous category (this included 34 cases of severe sepsis, which had a mortality of 65%). This was followed by cardiovascular precipitants (n = 424) in which there were 147 deaths (35% mortality): these precipitants included blood loss (53%), embolism (61%) and myocardial infarction (70%). Airway and breathing events accounted for 25% and anaphylaxis 8%. A specialist anaesthetist attended the majority of these cardiac arrests. As webAIRS is a voluntary database, it is not possible to determine the incidence of perioperative cardiac arrest and only descriptive information on factors associated with cardiac arrest can be obtained. Nevertheless, the large number of reports includes a wide range of cases, precipitants, demographics and outcomes, providing ample opportunity to learn from these events. The data also provide rich scope for further research into further initiatives to prevent cardiac arrest in the perioperative period, and to improve outcomes, should a cardiac arrest occur.
Hughes H. Public inquiries, patient safety and the implementation gap. Future Healthc J. 2023;10(1):7-9.
Keywords: Patient Safety Learning; Patient safety; blame culture; healthcare safety investigations; implementation; patient harm; safety management.
Abstract
A decade on from the Francis report, avoidable patient harm continues to occur and we have continued to see new inquiries and reviews into serious patient safety scandals. A failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework are alarming and often reported themes that we review here.
Eley VA, Culwick MD, Dennis AT. Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022. Anaesth Intensive Care. 2023 Nov;51(6):391-399.
Keywords: Anaesthetists; Australia; New Zealand; caesarean section; incident reporting; medication errors; webAIRS.
Abstract
Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications.
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.
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
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
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.
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.
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.
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Fifth report of the Perioperative Mortality Review Committee ;(the POMRC). Report to the Health Quality & Safety Commission New Zealand (June 2016)