Significant Physiological Disturbances Associated With Non-Routine Event Containing and Routine Anesthesia Cases

Slagle, Jason; Anders, Shilo; Porterfield, Eric; Arnold, Alexandra; Calderwood, Charles; Weinger, Matthew B.

doi:10.1097/pts.0000000000000081

Cited by 8 publications

(9 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This would facilitate event verification, as well as provide rich data to understand timing, contributing factors, and consequences of the event and its management. In studies in the operating room, videotaping NREs has been shown to be feasible and have merit (Oken et al, 2007; Slagle et al, 2015). Third, the identification and coding of MREs were based solely on the nurse's report without corroborating with other sources of data (e.g., the medical record).…”

Section: Discussionmentioning

confidence: 99%

“…The percentage of observations that would contain at least one MRE was estimated to be 35% based on previous research (Oken et al, 2007; Slagle et al, 2015). The results from G*Power software (Faul, Erdfelder, Lang, & Buchner, 2007) recommended a sample size of N = 152.…”

Section: Methodsmentioning

confidence: 99%

“…However, traditional quality assurance programs and voluntary medication event reporting systems have important limitations. For example, most of these reporting systems only capture events that led to the occurrence or near occurrence of adverse outcomes, ignoring myriad other events that may also be harbingers of unsafe processes or conditions (Slagle et al, 2015). An alternative is the construct of “non-routine events” (NREs) that affords an efficient method for capturing a broad range of potentially dangerous conditions and process improvement opportunities (Oken et al, 2007; Weinger & Slagle, 2002).…”

Section: Facilitated Nurse Medication-related Event Reporting To Imprmentioning

confidence: 99%

See 2 more Smart Citations

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

Reale²,

Slagle

et al. 2017

Nursing Research

Self Cite

View full text Add to dashboard Cite

Background Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management—especially medication-related events (MREs)—provides an approach to analyze and improve medication safety and quality. Objectives The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies, and the relationship between MREs and nurses' work in the ICUs. Methods We conducted 124 structured four-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts. Results MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts. Discussion The majority of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Facilitated Nurse Medication-related Event Reporting To Imprmentioning

confidence: 99%

See 1 more Smart Citation

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

Reale²,

Slagle

et al. 2017

Nursing Research

Self Cite

View full text Add to dashboard Cite

show abstract

“…(13) Assessment of factors surrounding or associated with errors, such as non-error process deviations and significant physiologic disturbances, may help identify conditions that should lead teams to have increased vigilance for errors. In this initial study, we were unable to show an association between error frequency and the frequency of significant physiologic disturbances.…”

Section: Discussionmentioning

confidence: 99%

“…(13) We defined significant physiologic disturbances as vital sign values greater than two standard deviations from the mean for age based on published standards and desaturation defined as oxygen saturation <90%. (14–16) We identified significant physiologic disturbances by reviewing recordings of the patient monitor and team responses to significant physiologic disturbances by video review.…”

Section: Methodsmentioning

confidence: 99%

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

Webman

Fritzeen

Yang

et al. 2016

Journal of Trauma and Acute Care Surgery

View full text Add to dashboard Cite

Background Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm due to mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. Methods Errors identified using video analysis were classified as errors of omission or commission, and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. Results Thirty-nine resuscitations were reviewed, identifying 337 errors (range 2–26 per resuscitation). The most common errors were related to cervical spine stabilization (n=93, 27.6%). Errors of omission (n=135) and commission (n=106) were more common than errors of selection (n=96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p=0.03 and p=0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p=0.004 and p=0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. Conclusions Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. LEVEL OF EVIDENCE VI STUDY TYPE prognostic

show abstract

Assessment of Nonroutine Events During Intubation After Pediatric Trauma

Alberto

Amberson

Cheng

et al. 2021

Journal of Surgical Research

View full text Add to dashboard Cite

Significant Physiological Disturbances Associated With Non-Routine Event Containing and Routine Anesthesia Cases

Abstract: SPDs occur more often in NRE-containing cases. The incidence of approximately one NRE-independent SPD per case was similar in NRE-containing and routine case. Further research is needed to ascertain the relationship of both NREs and SPDs to patient outcomes.

Cited by 8 publications

References 29 publications

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

Assessment of Nonroutine Events During Intubation After Pediatric Trauma

Contact Info

Product

Resources

About