Reported Significant Observations During Anaesthesia: A Prospective Analysis Over an 18-Month Period

Chopra, V.; Bovill, J. G.; Spierdijk, J.; Koornneef, Floor

doi:10.1093/bja/68.1.13

Cited by 113 publications

(45 citation statements)

References 10 publications

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“…After these strategies are in place it is necessary to assess their effectiveness [8]. It has also been suggested that even in the case of heterogeneous results, targeting high priority areas could decrease the overall frequency of events [16].…”

Section: Discussionmentioning

confidence: 99%

Drug related critical incidents

Khan

Hoda

2004

Anaesthesia

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SummaryDrug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect ⁄ drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.

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Section: Discussionmentioning

confidence: 99%

Drug related critical incidents

Khan

Hoda

2004

Anaesthesia

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“…Critical incident reporting is a well established QA in clinical anaesthesia [1][2][3][4][5][6]. However, there are significant differences regarding patient management between the operating theatre and the ICU.…”

Section: Discussionmentioning

confidence: 99%

“…Despite major advances in staff training and patient monitoring, appreciable morbidity and mortality attributable to mishaps still occur. Critical incident reporting is well established in anaesthesia [1][2][3][4][5][6] and several studies have now been published which highlight the role of both active and latent errors in the genesis of critical incidents. Until recently, little information was available regarding critical incidents [7][8][9][10][11] occurring in critically ill patients in the ICU especially when technically sophisticated procedures are performed on acutely ill patients with unstable physiology.…”

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confidence: 99%

Critical incident reporting in the intensive care unit

et al. 1997

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SummaryCritical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our 'system' and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.

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“…Item error weighting was defined as follows: Weighting: 1) No risk: an incident without any potential risk for the patient; 2) Low risk: an incident which could have led to reversible damage to the patient; 3) Medium risk: an incident which could have led to irreversible damage to the patient; and 4) High risk: a potentially fatal incident. 6 Once the checklists were returned, they were anonymously collated and emailed back to the participants in round 2. Participants were then asked to check off whether the item should remain or be deleted, and to assign a weighting if it was a new item to them or re-assign a weighting if deemed appropriate.…”

Section: Methodsmentioning

confidence: 99%

Simulation performance checklist generation using the Delphi technique

Morgan

Lam-McCulloch

Herold-McIlroy

et al. 2007

Can J Anesth/J Can Anesth

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Purpose: Performance assessment using high fidelity simulation is problematic, due to the difficulty in developing valid and reliable evaluation tools. The Delphi technique is a consensus based content generation method used for multiple purposes such as policy development, best-evidence practice guidelines and competency assessments. The purpose of this study was to develop checklists using a modified Delphi technique to evaluate the performance of practicing anesthesiologists managing two simulated scenarios. Methods:The templates for two simulation scenarios were emailed to five anesthesiologists who were asked to generate performance items. Data were collated anonymously and returned. An a priori decision was made to delete items endorsed by ≤ 20% of participants. This process of collection, collation and re-evaluation was repeated until consensus was reached. Four independent raters used the checklist to assess three subjects managing the two simulation scenarios. Interrater reliability was assessed using average measures intraclass correlation (ICC) and repeated measures analysis of variance (ANOVA) was used to assess differences in difficulty between scenarios. Results:The final checklists included 131 items for scenario 1 and 126 items for scenario 2. The mean inter-rater reliability was 0.921 for scenario 1 and 0.903 for scenario 2. Repeated measures ANOVA revealed no statistically significant difference in difficulty between scenarios.Discussion: The Delphi technique can be very useful to generate consensus based evaluation tools with high content and face validity compared to subjective evaluative tools. Since there was no difference in scenario difficulty, these scenarios can be used to determine the effect of educational interventions on performance.

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Reported Significant Observations During Anaesthesia: A Prospective Analysis Over an 18-Month Period

Cited by 113 publications

References 10 publications

Drug related critical incidents

Drug related critical incidents

Critical incident reporting in the intensive care unit

Simulation performance checklist generation using the Delphi technique

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