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Pedersen TH, Nabecker S, Greif R, Theiler L, Kleine-Brueggeney M. Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system. Br J Anaesth 2024; 133:371-379. [PMID: 38866639 PMCID: PMC11282466 DOI: 10.1016/j.bja.2024.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/26/2024] [Accepted: 04/08/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. METHODS This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. RESULTS Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. CONCLUSIONS Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.
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Affiliation(s)
- Tina H Pedersen
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark
| | - Sabine Nabecker
- Department of Anesthesiology and Pain Management, Sinai Health System, University of Toronto, Toronto, ON, Canada.
| | - Robert Greif
- University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Lorenz Theiler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Maren Kleine-Brueggeney
- Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Loadsman JA, Cooper MG. Awards for papers published in Anaesthesia and Intensive Care, 2022. Anaesth Intensive Care 2024; 52:264. [PMID: 39075973 DOI: 10.1177/0310057x241257815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
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Patel S. Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route - A narrative review. Indian J Anaesth 2024; 68:439-446. [PMID: 38764957 PMCID: PMC11100648 DOI: 10.4103/ija.ija_1276_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/26/2024] [Accepted: 03/02/2024] [Indexed: 05/21/2024] Open
Abstract
Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.
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Affiliation(s)
- Santosh Patel
- Department of Anaesthesia, Tawam Hospital, Al Ain, Abu Dhabi, UAE
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Pinho RH, Nasr-Esfahani M, Pang DSJ. Medication errors in veterinary anesthesia: a literature review. Vet Anaesth Analg 2024; 51:203-226. [PMID: 38570267 DOI: 10.1016/j.vaa.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 12/18/2023] [Accepted: 01/16/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.
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Affiliation(s)
- Renata H Pinho
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada.
| | - Maryam Nasr-Esfahani
- University of Calgary, Cumming School of Medicine, Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB, Canada
| | - Daniel S J Pang
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Montreal, PQ, Canada
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Eley VA, Culwick MD, Dennis AT. Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022. Anaesth Intensive Care 2023; 51:391-399. [PMID: 37737092 DOI: 10.1177/0310057x231196915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications.
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Affiliation(s)
- Victoria A Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Martin D Culwick
- Australian and New Zealand Tripartite Anaesthetic Data Committee, Melbourne, Australia
| | - Alicia T Dennis
- Department of Anaesthesia, The Royal Women's Hospital, Melbourne, Australia
- Faculty of Health, Deakin University, Geelong, Australia
- Departments of Critical Care, Obstetrics and Gynaecology, and Pharmacology, University of Melbourne, Melbourne, Australia
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Mistry MM, Endlich Y. Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS. Anaesth Intensive Care 2023; 51:408-421. [PMID: 37786341 DOI: 10.1177/0310057x231198255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.
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Affiliation(s)
- Manisha M Mistry
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Yasmin Endlich
- Department of Anaesthesia and Acute Pain Medicine, Royal Adelaide Hospital, Adelaide, Australia
- Department of Paediatric Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia
- Faculty of Anaesthesia, University of Adelaide, Adelaide, Australia
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Gibbs NM. Clinical incident reporting: Extending the learning opportunities through webAIRS. Anaesth Intensive Care 2023; 51:372-374. [PMID: 37802487 DOI: 10.1177/0310057x231200508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
- The University of Western Australia, Nedlands, Australia
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Gibbs NM, Culwick MD, Endlich Y, Merry AF. A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Anaesth Intensive Care 2021; 49:422-429. [PMID: 34894746 DOI: 10.1177/0310057x211060846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.
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Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, 5728Sir Charles Gairdner Hospital, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yasmin Endlich
- Department of Anaesthesia, Royal Adelaide Hospital and Women and Children's Hospital, Adelaide, Australia
| | - Alan F Merry
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand This article is a copy of a report submitted to the Australian and New Zealand Tripartite Anaesthesia Data Committee (ANZTADC). It is published on behalf of ANZTADC at their request and with their permission. It has not been subject to peer review
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