Human error poses significant risk for hospitalized patients causing an estimated 100,000 to 400,000 deaths in the USA annually. Medication errors contribute, with error occurring in 5.3% of medication administrations during surgery. In this study 70.3% of medication errors were deemed preventable. Given the paucity of randomized controlled studies, we undertook a rigorous review of the literature to identify recommendations supported by expert opinions. An extensive literature search pertaining to medication error, medication safety, operating room, and anaesthesia was performed. The National Guidelines Clearinghouse was searched for any anaesthesia or operating room medication safety guidelines.A total of 74 articles were included. Recommendations were tabulated and assigned points based on a scale revised from a prior study. A total of 138 unique recommendations were identified, with point tallies ranging from 4 to 190. An in-person focus meeting occurred, where the 138 recommendations were reviewed, combined and condensed. A modified Delphi process was used to eliminate items found to be unimportant or those unable to be quantified (e.g. "minimize fatigue"). A total of 35 specific recommendations remained. Adverse events as a result of medication errors occur frequently in the operative setting. There are few rigorous studies to direct medication safety strategies, but this should not lead us to do nothing. The overwhelming consensus regarding best practices should be accepted, and the recommendations implemented. Our list of recommended strategies can hopefully be used to assess local vulnerabilities and institute system solutions.
Current published guidelines for perioperative pharmacy services have limited information on the development and implementation of a robust clinical pharmacy program across the surgical continuum of care. This publication defines the responsibilities and scope of practice of the Perioperative Clinical Pharmacist (PCPh), supporting the PCPh as a critical member of the interprofessional surgical patient care team. Opportunities for pharmacist role integration into perioperative medication management processes are described along with published examples of successful PCPh practice models, including those with interventions targeted toward Enhanced Recovery Pathways (ERP). Recommended training and competencies for future and practicing perioperative pharmacists, in addition to considerations for precepting and scholarly activities, are also outlined. Finally, future developments in perioperative pharmacy practice are discussed, including technological advancements, improved predictive models, and expansion of collaborative practice agreements.
IntroductionThe perioperative period is high risk for older adults. Depression and anxiety are common perioperative problems, frequently coexisting with cognitive impairment. Older patients with these conditions are more likely than younger patients to experience postoperative delirium, long hospital stays, poor quality of life and rehospitalisation. These experiences can, in turn, exacerbate anxiety and depressive symptoms. Despite these risks, little is known about how to treat perioperative anxiety and depression among older adults.Methods and analysisWe designed a feasibility study of a perioperative mental health intervention bundle to improve perioperative mental health, specifically depression and anxiety. The overarching goals of this study are twofold: first, to adapt and refine an intervention bundle comprised of behavioural activation and medication optimisation to meet the needs of older adults within three surgical patient populations (ie, orthopaedic, oncological and cardiac); and second, to test the feasibility of study procedures and intervention bundle implementation. Quantitative data on clinical outcomes such as depression, anxiety, quality of life, delirium, falls, length of stay, hospitalisation and pain will be collected and tabulated for descriptive purposes. A hybrid inductive–deductive thematic approach will be employed to analyse qualitative feedback from key stakeholders.Ethics and disseminationThe study received approval from the Washington University Institutional Review Board. Results of this study will be presented in peer-reviewed journals, at professional conferences, and to our perioperative mental health advisory board.Trial registration numberNCT05110690.
BACKGROUND: Thoracic epidural analgesia has been shown to be an effective method of pain control. The utility of epidural analgesia as part of an enhanced recovery after surgery protocol is debatable. OBJECTIVE: This study aimed to determine if the use of thoracic epidural analgesia in an enhanced recovery after surgery protocol decreases hospital length of stay or inpatient opioid consumption after elective colorectal resection. DESIGN: Single institution retrospective cohort study. SETTINGS: The study was performed at a high volume, tertiary care center in the Midwest. An institutional database was used to identify patients. PATIENTS: All patients undergoing elective transabdominal colon or rectal resection by board certified colon and rectal surgeons from 2013 to 2017. MAIN OUTCOME MEASURES: The main outcome was length of stay. The secondary outcome was oral morphine equivalents consumed during the first 48 hours. RESULTS: There were 1006 patients (n=815 epidural, 191 no epidural) included. All patients received multimodal analgesia with opioid sparing agents. Univariate analysis demonstrated no difference in length of stay between those who received thoracic epidural analgesia and those who did not (median 4 vs. 5 days, p=0.16), which was substantiated by multivariable linear regression. Subgroup analysis showed the addition of epidural analgesia resulted in no difference in length of stay regardless of open (n=362, p=0.66) or minimally invasive (n=644, p=0.46) approach. Opioid consumption data was available since 2015 (n=497 patients). Univariate analysis demonstrated no difference in morphine equivalents consumed in the first 48 hours between patients who received epidural analgesia and those who did not (median 135 vs. 110 oral morphine equivalents, p=0.35). This was also confirmed by multivariable linear regression. LIMITATIONS: Retrospective observational design. CONCLUSION: The use of thoracic epidural analgesia within an enhanced recovery after surgery protocol was not found to be associated with a reduction in length of stay or morphine equivalents consumed within the first 48 hours. We cannot recommend routine use of thoracic epidural analgesia within enhanced recovery after surgery protocols. See Video Abstract at http://links.lww.com/DCR/Axxx.
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