Safety & quality resources: Journals & articles

Abstract
Background: Junior anaesthesiologists often find it difficult to gain the trust of surgeons, possibly because of their limited experience and unfamiliarity with surgeons. Therefore, they can face pressure when navigating disagreements with senior surgeons. We investigated whether and how differences in anaesthesiologist-surgeon seniority might impact patient safety.

Methods: This was a sequential explanatory, mixed-methods evaluation conducted at a general hospital, comprising a retrospective case-control study followed by semi-structured interviews. In the quantitative phase, the case group included surgical patients who experienced anaesthesia-related adverse events. The control group was randomly selected from surgical patients without adverse events, matched to the case group by surgeon, surgery, and surgery year. The exposure was the differences in work experience between anaesthesiologists and surgeons. For the qualitative phase, participants were recruited from attending anaesthesiologists using a theoretical sampling strategy, and a grounded theory analysis was performed.

Results: The quantitative study included 390 patients in the case group and 1560 patients in the control group. After controlling for confounders, we did not find a significant association between differences in anaesthesiologist-surgeon seniority and odds of anaesthesia-related adverse events (adjusted odds ratio 1.00, 95% confidence interval 0.98-1.01, P=0.634). In cases of disagreements among surgeons, anaesthesiologists primarily based clinical decisions on the potential impact on patient safety. Junior anaesthesiologists faced challenges when rejecting surgeons. Nevertheless, they received robust support from anaesthesiology colleagues.

Conclusions: The capacity of anaesthesiologists to uphold patient safety was not significantly affected by their seniority levels relative to surgeons.

Abstract
The concept of ambidexterity as a strategic advantage has been discussed extensively in the business literature. While the specialty of anesthesiology has mastered exploitative/variance-reducing tactics as well as any specialty in health care, a new perspective of exploratory/variance-increasing strategies will be necessary to remain relevant in the perioperative space. We offer a framework of "idea flow" as a means for anesthesiology groups and departments to balance ongoing clinical mastery with innovative exploration.

Abstract
Anesthesiologists are perioperative leaders of patient and health care team safety. The anesthesiologist needs to remain vigilant in the perioperative setting and while caring for patients. The ability to navigate increased noise levels, distractions, and hazards is crucial for maintaining a safe environment. While some noise, such as music, can have benefits, overall noise levels can distract from patient care and have adverse effects on patient care and intraoperative staff. This study provides an overview of noise, distractions, and hazards in the perioperative environment.

Abstract
During the past 70 years, patient safety science has evolved through four organizational frameworks known as Safety-0, Safety -1, Safety-2, and Safety-3. Their evolution reflects the realization over time that blaming people, chasing errors, fixing one-offs, and regulation would not create the desired patient safety. In Safety-0, the oldest framework, harm events arise from clinician failure; event prevention relies on better staffing, education, and basic standards. In Safety-1, used by hospitals, harm events arise from individual and/or system failures. Safety is improved through analytics, workplace culture, high reliability principles, technology, and quality improvement. Safety-2 emphasizes clinicians' adaptability to prevent harm events in an everchanging environment, using resilience engineering principles. Safety-3, used by aviation, adds system design and control elements to Safety-1 and Safety-2, deploying human factors, design-thinking, and operational control or feedback to prevent and respond to harm events. Safety-3 represents a potential way for anesthesia and perioperative care to become safer.

Abstract
Background: Reducing the prevalence of hospital-acquired complications (HACs) is paramount for both patient safety and hospital financial performance because of its impact on patient's recovery and health service delivery by diverting resources away from other core patient care activities. While numerous reports are available in the literature for projects that successfully reduce specific HAC, questions remain about the sustainability of this isolated approach and there may be benefits for more wholistic programmes that aim to align prevention strategies across a hospital. This study describes such a programme that uses evidence and theories in the literature to achieve and sustain a reduction in HACs in an Australian local health service between 2019 and 2022.

Methods: An organisation-wide HACs Reduction Programme underpinned by a 3-pillar strategic framework (complete documentation, accurate coding, clinical effectiveness) and a 5-year roadmap to clinical excellence was developed. Priorities were identified through Pareto analysis and aligned at organisational, service and specialty levels. The Institute for Healthcare Improvement (IHI) 90-day cycle was modified to implement contextualised evidence-based interventions supported by the application of the Awareness, Desire, Knowledge, Ability and Reinforcement change management model. Under this wholistic umbrella, specific projects were data-driven, evidence-based and outcome-oriented to promote clinical engagement and a continuous improvement culture.

Results: Overall mean HAC rate per 10 000 episodes of care decreased from a baseline of 459.5 across 2017 and 2018 to 363.1 in 2019 and remained lower through to the end of 2022 indicating sustained improvement in performance.

Conclusion: A wholistic approach to reduce HACs increased the likelihood of multidisciplinary integration for contextualised strategies and interventions. Improvement work, particularly in relation to patient outcomes, is a dynamic process that needs to be intentionally cultivated, targeted and coordinated. The modified IHI 90-day cycle proved to be an effective tool for implementation that contributed to sustained change.

Abstract
Background: The COVID-19 pandemic generated or accelerated healthcare changes, some of which persist thereafter (e.g., healthcare reorganisation, remote consultation). Such changes entail novel risks for patient safety.

Methods: Aim To compare the characteristics of patient safety incidents with harm (PSIH) in primary care before the pandemic and at present. Design and setting Cross-sectional, comparative, observational study conducted within the entire Primary Care Service of the Madrid region with observations at two time points (2018 and 2021/2022). Participants Patients > 18 years of age with at least one consultation in the previous year. The necessary sample size was established at N1 = 2,000 for the first time point and N2 = 2,700 for the second. Sampling was performed by simple randomisation for the first group and by clusters followed by simple randomisation for the second. Main measurements Age, gender, presence of PSIH in the medical record, and characteristics of the PSIH, specifically avoidability, severity, place of occurrence, nature, and contributory factors. Triggers validated in primary care were employed to screen the patients' medical records and those containing any trigger were reviewed by three nurse-physician teams who underwent previous training. Analysis Comparative analysis using Fisher's exact test.

Results: A total of 63 PSIHs and 25 PSIHs were found for the first and second samples, respectively. The comparison of the characteristics of PSIH before the pandemic and currently was: avoidable 62% vs. 52% (p = 0.47), mild 51% vs. 48% (p = 0.57), in the primary care setting 73% vs. 64% (p = 0.47), respectively. Although no statistically significant differences were observed globally in the nature of the incidents (p = 0.13), statistically significant differences were found for diagnostic errors, with pre-pandemic rates of 6% vs. 20% at present (p < 0.05). Finally, no significant differences were found in the contributory factors.

Conclusions: No differences were found in the avoidability, severity, place of occurrence, or contributory factors of PSIHs before the pandemic and currently. In terms of the nature of these incidents, the outcomes revealed an increase in diagnostic errors (excluding diagnostic tests), which could be attributed to a greater frequency of remote consultations and a decrease in the longitudinality of care resulting from the shortage of professionals.

Abstract
Objectives: To estimate the frequency, severity, and preventability of adverse events associated with perioperative care, and to describe the setting and professions concerned.

Design: Multicenter retrospective cohort study.

Setting: 11 US hospitals.

Participants: 1009 patients from a randomly selected sample of 64 121 adults admitted for surgery during 2018.

Main outcome measures: Adverse events during inpatient perioperative care were assessed using a trigger method, identifying information previously associated with similar events, and from a comprehensive review of electronic health records. Trained nurses reviewed all records and flagged admissions with possible adverse events, which were then adjudicated by physicians, who confirmed the occurrence and characteristics of the events. Adverse events were classified as major if they resulted in serious harm requiring substantial intervention or prolonged recovery, involved a life threatening event, or led to a fatal outcome. Potentially preventable events included those definitively, probably, or possibly preventable.

Results: Among 1009 patients reviewed, adverse events were identified in 38.0% (95% confidence interval 32.6 to 43.4), with major adverse events occurring in 15.9% (12.7 to 19.0). Of 593 identified adverse events, 353 (59.5%) were potentially preventable and 123 (20.7%) were definitely or probably preventable. The most common adverse events were related to surgical procedures (n=292, 49.3%), followed by adverse drug events (n=158, 26.6%), healthcare associated infections (n=74, 12.4%), patient care events (n=66, 11.2%), and blood transfusion reactions (n=3, 0.5%). Adverse events were most frequent in general care units (n=289, 48.8%), followed by operating rooms (n=155, 26.1%), intensive care units (n=77, 13.0%), recovery rooms (n=20, 3.3%), emergency departments (n=11, 1.8%), and other in-hospital locations (n=42, 7.0%). Professions most involved were attending physicians (n=531, 89.5%), followed by nurses (n=349, 58.9%), residents (n=294, 49.5%), advanced level practitioners (n=169, 28.5%), and fellows (n=68, 11.5%).

Conclusions: Adverse events were identified in more than one third of patients admitted to hospital for surgery, with nearly half of the events classified as major and most potentially preventable. These findings emphasize the critical need for ongoing improvement in patient safety, involving all health professionals, throughout perioperative care.

Abstract
Objective: To analyze the effect of an improvement project on the implementation of Basic Patient Safety Protocols in Brazilian public hospitals.

Method: This is an intervention study aimed at comparing measurements before-and-after the implementation of an improvement project in 35 public hospitals across three Brazilian regions, between July 2021 and September 2023. The intervention consisted of a set of activities to support the implementation of six Basic Patient Safety Protocols, with semimonthly collection of indicators. The data were analyzed using descriptive statistics, with the use of trend charts to demonstrate improvements, considering the first seven collection points as the baseline for comparisons.

Results: After the intervention period, all Patient Safety Protocols showed improvements in their indicators. The prevention of falls and safe surgery stood out, with a 73% reduction in prevalence and a 675% increase in adherence to the safe surgery checklist, respectively, compared to the group of hospitals.

Conclusion: The improvement project had a positive effect on patient safety in the institutions, evidenced by the improvement in indicators of all analyzed protocols.

Abstract
Prompt recognition and management of critical events is pivotal for the provision of safe anesthetic care. This requires a well-functioning team that focuses on effective communication, timely decision-making, and escalation of potential complications. We believe that variation in bedside care leads to "near-misses," adverse outcomes, and serious safety events (SSEs). The principles of an escalation culture have been used successfully in other highly reliable industries such as aviation, military, and manufacturing. We discuss here the introduction of a unique and compelling thought-process for developing an intraoperative escalation protocol that is specifically tailored for our institution. Inspired by a critical intraoperative event, this departmental protocol was developed based on an analysis of multispecialty literature and expert opinion to decrease the incidence of SSEs. It includes a stepwise approach and incorporates patient-specific information to guide team members who encounter dynamic clinical situations. The implementation of the protocol has facilitated continuous quality improvement through iterative education, improving communication, and enhancing decision-making. Concurrently, we have plans to incorporate technology and electronic decision support tools to enhance real-time communication, monitor performance, and foster a culture of safety.

Abstract
A report on participant views of a two-person check confirming tracheal intubation implemented in their institution found that this check was generally considered feasible and useful, but there was some resistance and some concerns that it would not solve the problem. Social, cultural, and cognitive factors play a role in airway management in the operating theatre, partly because of the pre-eminence of airway management as a cornerstone of the profession of anaesthesia. These factors contribute to loss of situation awareness in airway failure. Although situation awareness might be better maintained by the two-person check, there could be advantages if airway management became the responsibility of the whole operating theatre team. Potential strategies to overcoming the ongoing problem of failed airway management are proposed, including multidisciplinary team training in airway management and a new airway point in the surgical safety checklist time out.

Abstract
Purpose of review: To explore the collaboration between human factors (HFs) experts and clinicians in order to improve perioperative patient safety.

Recent findings: Recent recommendations to integrate human factors into anesthesia in the United Kingdom emphasizes the value of applying disciplines outside of medicine to optimize the patient experience.

Summary: Human factors engineering is underutilized worldwide. Patient safety would benefit from collaboration with HF experts to design resilient systems. Healthcare organizations must consider HF to develop and implement user-centered solutions to improve safety for patients and professionals.

Abstract
Purpose of review: Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

Recent findings: Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

Summary: In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

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?

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.

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.

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.

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.

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.

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.

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