Error detection: A study in anaesthesia

Nyssen, Anne‐Sophie; Blavier, Adelaïde

doi:10.1080/00140130600568766

Cited by 34 publications

(20 citation statements)

References 15 publications

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“…10 This limitation can make the study of medication errors/ pre-errors difficult and expensive, which, in both instances, may inhibit study. Key features of this study were the ongoing reassurance to anesthesia providers in the department that this study was being conducted in a ''nonthreatening'' environment; responses were voluntary and anonymity was guaranteed; and the data obtained would lead to improved medical care.…”

Section: Resultsmentioning

confidence: 99%

“…5 Factors associated with medication errors/ pre-errors occurring within the operating room include personal distractions; production pressure; inadequate communication between medical caregivers; exposure to new, unexpected, or unfamiliar medication vials or labels; and misread/look-alike medication vials or ampules. 1,3,4,10 The aim of this prospective unblinded observational study was to determine whether the type of surgical case, the American Society of Anesthesiologists' (ASA) physical status classification, the level of experience of the anesthesia provider, or other factors impact the frequency and reporting of medication errors/pre-errors in a tertiary care academic teaching hospital. This study extends previous work by Webster et al 1 …”

Section: Introductionmentioning

confidence: 99%

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Influences observées sur l’incidence et le signalement des erreurs médicamenteuses en anesthésie

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

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Background Medication errors are a common occurrence during the conduct of anesthesia (one in 113-450 patients). Several factors contribute to medication errors in anesthesia, including experience of the anesthesia provider, severity of comorbidities, and type of procedure. The inexperience of anesthesia providers-in-training also leads to increased error rates. This prospective observational study repeats and extends previous work by Webster et al. and Llewellyn et al. examining the role of comorbidities, type of case, and level of provider experience on the incidence of medication errors. Methods After Institutional Review Board review and exemption from informed consent, medication error reporting forms were attached to every anesthetic record during a six-month period. All providers were asked to return the forms for every anesthetic, on a strictly voluntary and anonymous basis, and to record the occurrence of medication errors. If providers indicated that a medication error had occurred, additional details about the event were obtained anonymously. Results There were 8,777 (83%) responses obtained in a review of 10,574 case forms. A medication error was reported in 35 forms, with an additional 17 forms indicating a medication pre-error or near miss, resulting in 52 (0.49%) errors/pre-errors or a reported incidence of 1:203 anesthetics. Most case types were observed to have a statistically significant increase in reported medication errors. Reported errors by type of anesthesia provider were categorized into anesthesia provider-in-training group and the experienced provider group. The anesthesia providerin-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Influences observées sur l’incidence et le signalement des erreurs médicamenteuses en anesthésie

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

show abstract

“…Error identification and recovery is not traditionally taught or evaluated in residency training [39], and there is significant potential for such processes to be formalised. It has been demonstrated that routine monitoring of the environment was the main source of detected errors in anaesthesia [40]. Increasing standard check frequency during critical periods demonstrates great potential to mitigate fatigue-related risk.…”

Section: Fatigue Proofing Strategiesmentioning

confidence: 99%

Fatigue-related risk management in the emergency department: a focus-group study

et al. 2018

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Fatigue has major implications on both patient safety and healthcare practitioner's well-being. Traditionally, two approaches can be used to reduce fatigue-related risk: reducing the likelihood of a fatigued operator working (i.e. fatigue reduction), or reducing the likelihood that a fatigued operator will make an error (i.e. fatigue proofing). Recent progress mainly focussed on fatigue reduction strategies such as reducing work hours. Yet it has to be recognized that such approach has not wholly overcome the experience of fatigue. Our purpose is to investigate individual proofing and reduction strategies used by emergency physicians to manage fatigue-related risk. 25 emergency physicians were recruited for the study. Four focus groups were formed which consisted of an average of six individuals. Qualitative data were collected using a semi-structured discussion guide unfolding in two parts. First, the participants were asked to describe how on-the-job fatigue affected their efficiency at work. A mind map was progressively drawn based upon the participants' perceived effects of fatigue. Second, participants were asked to describe any strategies they personally used to cope with these effects. We used inductive qualitative content analysis to reveal content themes for both fatigue effects and strategies. Emergency physicians reported 28 fatigue effects, 12 reduction strategies and 21 proofing strategies. Content analysis yielded a further classification of proofing strategies into self-regulation, task re-allocation and error monitoring strategies. There is significant potential for the development of more formal processes based on physicians' informal strategies.

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“…These involve evaluation of complex interacting components of systems that have synergistic effects, including between the type of error detected and the error detection mode. 40 Some kinds of interventions, such as the use of barcode technology in preventing medication dispensing errors, may ostensibly be suited to quantitative variable-oriented approaches to capture intervention effects on specific error rates. 42 However, they have their Peer-Reviewed Papers: Understanding Performance limits for more holistic small-N studies involving complex interventions.…”

Section: Contextual Authenticitymentioning

confidence: 99%

“…38,39 Accordingly, any number and combination of changes in staffing, training, equipment, supervision, or latent environmental factors may be at work synergistically to produce the effects being observed. 25 Evaluations of the efficacy of error detection systems 40 and error recovery strategies 41 form another important but often neglected area of enquiry. These involve evaluation of complex interacting components of systems that have synergistic effects, including between the type of error detected and the error detection mode.…”

Section: Contextual Authenticitymentioning

confidence: 99%

Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance?

Bell

2007

Aust. Health Review

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This paper aims to provide hospital administrators and others making decisions about hospital error funding, as well as researchers, with information about what good hospital error research looks like. It offers a selective review of how the error literature has approached hospital error, which is used to develop five criteria for sound hospital error research. It also explores the potential for better hospital error research of quali-quantitative analysis (QQA), an innovative social sciences research method. In a context in which other methodologies all have their shortcomings, QQA appears to go some way toward meeting the five criteria for sound hospital error research. Ideally, QQA would be used in combination with other approaches to answer the kinds of questions that are important to hospital administrators when they are faced with high-stakes CONSIDERABLE MEDIA AND POLICY attention is given to the high stakes "unusual cases" (such as error and/or professional misconduct) in hospital service delivery. But how can hospital administrators and policy decision makers prevent such cases from happening in the first place? This paper describes the research methods that have been used to understand hospital error. It also explores the potential of a transdisciplinary research method (quali-quantitative analysis[QQA]) for understanding hospital error and its causes, particularly in small-N studies.Without sound practices for investigating and preventing errors, the most accurate and full error reporting systems are meaningless. Knowledge about what works and what doesn't in error research methodology is critical to managing error. Accordingly, this paper aims to provide information and criteria for deciding on the kind of study of hospital error likely to deliver sound evidence for policy and practice. The paper should also be of interest to researchers of hospital error interested in questions of research technique.

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Error detection: A study in anaesthesia

Cited by 34 publications

References 15 publications

Influences observées sur l’incidence et le signalement des erreurs médicamenteuses en anesthésie

Influences observées sur l’incidence et le signalement des erreurs médicamenteuses en anesthésie

Fatigue-related risk management in the emergency department: a focus-group study

Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance?

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