Inadequate pre‐operative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study

Abstract

SummaryThe Australian Incident Monitoring Study database was examined for incidents involving inadequate pre-operative patient preparation and/or evaluation. Of 6271 reports, 727 had appropriate keywords, of which 197 (3.1%) were used for subsequent analysis. All surgical categories were represented. In 10% of reports the patient was not reviewed pre-operatively by an anaesthetist, whilst in 23% the anaesthetist involved in the operating theatre had not performed the pre-operative assessment. Death followed in seven cases, major morbidity in 23 cases, admission to a high-dependency unit or intensive care unit in 17 cases, and surgery was cancelled in nine cases. Poor airway assessment, communication problems and inadequate evaluation were the most common contributing factors. Respondents indicated that the incident was preventable in 57% of cases. Proposed corrective strategies include improved communication, quality assurance activities, development of protocols and additional training. A structured assessment of the airway, along with improvements in information exchange, patient assessment, and use of clearly defined patient management plans and pathways would prevent most of the incidents reported. It is essential that all patients undergoing anaesthesia have a pre-operative assessment and management plan. The traditional method of pre-operative preparation involves reviewing the patient the night before surgery, examining the results of investigations ordered by the surgical house officers and ordering premedicant drugs. Evolving anaesthetic practices along with financial constraints have changed this pre-operative process with the advent of dedicated pre-operative clinics staffed by other professionals and an increasing focus on day surgery and day of surgery admission. This has rationalised pre-operative investigations, reduced direct anaesthetist±patient contact prior to surgery and increased reliance on anaesthetists assessing patients for other colleagues.

Acquisition and maintenance of endoscopic skills: developing an endoscopic dexterity training system for anesthesiologists

“…[1][2][3][4] The role of fibreoptic intubation in situations of both recognized and unrecognized difficult intubation is well established. [5][6][7][8] The requirement for fibreoptic equipment, trained personnel and for the teaching of trainees and staff is internationally acknowledged 9,10 and highlighted by accreditation, 11 audit 3 and professional bodies.…”

“…1,3 The Australian Incident Monitoring Study 1 reported "poor assessment of the airway" as the most common preoperative contributing factor to a subsequent critical incident. Of 23 known or suspected difficult airways, "…in the majority of cases a 'standard' anaesthetic technique was used rather than one more appropriate for this situation.…”

Development of an orthopedic surgery trauma patient handover checklist

“…1 The risks to patient care associated with handover have been extensively studied among health care workers, including personnel from prehospital care, emergency department, nursing, intensive care unit (ICU), anesthesiology, general surgery, plastic surgery, neurosurgery and orthopedic surgery. [2][3][4][5][6][7][8][9][10][11][12] Many groups have proposed handover checklists as a manner to improve information retention and handover safety. [13][14][15][16][17] Medical errors are common, occurring in 3.2%-10.6% of patients, 18,19 and it is estimated that 58%-66% of these errors will result in patient injury.…”

“…21,22 Although not specific to surgery, communication breakdown is a major factor in many cases of medical error. 2,6,10,16,18,21,22 This lack of or miscommunication leads to cognitive overload, duplication of tests, missing data, medication errors, delayed diagnosis or treatment, increased length of stay in hospital (LOS) and poor patient care outcomes. [23][24][25][26] Lack of information has been demonstrated in verbal handovers alone, whereas using both verbal and printed notes may result in the retention of up to 99% of the information.…”

‘Where there is error, may we bring truth.’A misquote by Margaret Thatcher as she entered No 10, Downing Street in 1979

“…Large studies report dramatic figures such as those recorded by The Times headline and suggest that up to 70% of adverse events are preventable [7][8][9]. However, the true prevalence and magnitude of errors is unknown despite these epidemiological reviews.…”