Jennifer Weller

Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study

A safety‐orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74 478 anaesthetics were included, for which 59 273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183 852 drug administrations (0.032%, 95% CI 0.024–0.041%) vs 268 in 550 105 (0.049%, 95% CI 0.043–0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006–0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re‐design can reduce medical error.

The impact of trained assistance on error rates in anaesthesia: a simulation‐based randomised controlled trial*

Trained assistance for the anaesthetist appears likely to improve safety in anaesthesia. However, there are few objective data to support this assumption, and the requirement for a trained assistant is not universally enforced. We applied a simulation‐based model developed in previous work to test the hypothesis that the presence of a trained assistant reduces error in anaesthesia. Ten randomly selected anaesthetists, five trained anaesthetic technicians and five theatre nurses without training in anaesthesia participated in two simulated emergencies, with anaesthetists working alternately with a technician or a nurse. The mean (SD) error rate per scenario was 4.75 (2.9). There were significantly fewer errors in the technician group than the nurse group (33 vs 62, p = 0.01) and this difference remained significant when errors were weighted for severity. This provides objective evidence supporting the requirement for trained assistance to the anaesthetist, and furthermore, demonstrates that a simulation‐based model can provide rigorous evidence on safety interventions in anaesthesia.

A simulation design for research evaluating safety innovations in anaesthesia

It is notoriously difficult to obtain evidence from clinical randomised controlled trials for safety innovations in healthcare. We have developed a research design using simulation for the evaluation of safety initiatives in anaesthesia. We used a standard and a modified scenario in a human‐patient simulator, involving a potentially life‐threatening problem requiring prompt attention – either a cardiac arrest or a failure in oxygen supply. The modified scenarios involved distractions such as loud music, a demanding and uncooperative surgeon, telephone calls and frequent questions from a medical student. Twenty anaesthetics were administered by 10 anaesthetists. A mean (SD) of 11.3 (2.8) errors per anaesthetic were identified in the oxygen failure scenarios, compared with 8.0 (3.4) in the cardiac arrest scenarios (ANOVA: p = 0.04). The difference between the combined standard scenarios and the combined modified scenarios was not significant. The mean rate of errors overall was 9.7 per simulation, with a pooled SD of 4.46, so in future studies 21 subjects would provide 80% statistical power to show a reduction in error rate of 30% from baseline with p≤0.05. Our research design will facilitate the evaluation of safety initiatives in anaesthesia.

Anaesthetists' management of oxygen pipeline failure: room for improvement*

Oxygen pipeline failure is a rare but potentially catastrophic event which can affect the care of patients throughout an entire hospital. Anaesthetists play a critical role in maintaining patient safety, and should be prepared to support an institution‐wide emergency response if oxygen failure occurs. We tested the preparedness for this through observation of 20 specialist anaesthetists to a standardised simulator scenario of central oxygen supply failure. Responses were documented using multiple approaches to ensure accuracy. All anaesthetists demonstrated safe immediate patient care, but we observed a number of deviations from optimal management, including failure to conserve oxygen supplies and, following restoration of gas supplies, failure to test the composition of the gas supplied from the repaired pipelines. This has implications for patient care at both individual and hospital level. Our results indicate a gap in anaesthesia training which should be addressed, in conjunction with planning for effective hospital‐wide responses to the event of critical resource failure.

Improving the Quality and Safety of Patient Care in Cardiac Anesthesia

From the *Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland; †Auckland City Hospital; and ‡Centre for Medical and Health Sciences Education, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. Address reprint requests to Alan Merry, FANZCA, University of Auckland, Department of Anaesthesiology, Private Bag 92019, 2 Park Road, Grafton, Auckland 1023, New Zealand. E-mail: a.merry@ auckland.ac.nz & 2014 Elsevier Inc. All rights reserved. 1053-0770/2601-0001

I. Best practice and patient safety in anaesthesia

36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.02.018

Validation of a measurement tool for self-assessment of teamwork in intensive care

The pursuit of patient safety involves reducing the gap between best practice and the care actually delivered to patients. Understanding how to reliably deliver best practice care using established anaesthetic techniques may, today, be more important than seeking new ones. Advances in anaesthesia safety involve analysing failures and devising strategies to address these. However, anaesthetists do not work in isolation, and their contribution to the function of the multidisciplinary teams in which they work has far-reaching consequences for patient care.

Improving procedural performance through warm-up and mental imagery

BACKGROUND Teamwork is an important contributor to patient safety and a validated teamwork measurement tool could help healthcare teams identify areas for improvement and measure progress. We explored the psychometric properties of a teamwork measurement tool when used for self-assessment. We hypothesized that the tool had a valid factor structure and that scores from participants and external assessors would correlate. METHODS Forty intensive care teams (one doctor, three nurses) participated in four simulated emergencies, and each independently rated their teams performance at the end of each case using the teamwork measurement tool, without prior training in the use of the tool. We used exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and compared factor structure between participants and external assessors (using previously reported data). Scores from participants and external assessors were compared using Pearsons correlation coefficient. RESULTS EFA demonstrated items loaded onto three distinct factors which were supported by the CFA. We found significant correlations between external and participant scores for overall teamwork scores and the three factors. Participants agreed with external assessors on the ranking of overall team performance but scored themselves significantly higher than external assessors. CONCLUSIONS The teamwork measurement tool has a valid structure when used for self-assessment. Participant and external assessor scores correlated significantly, suggesting that participants could discriminate between different levels of performance, although leniency in self-assessed scores indicated the need for calibration. This tool could help structure reflection on teamwork and potentially facilitate self-directed, workplace-based improvement in teamwork.

Perceptions du but, de la valeur et du processus du mini-Exercice d’évaluation clinique dans la formation en anesthésie

Anaesthetists are expected to develop and maintain expertise in procedural skills with low or zero tolerance for error. The more complex technical skills, as required for advanced airway management or ultrasound-guided procedures, require expertise in navigation, hand–eye coordination, and visualizing distant structures. Furthermore, learning andmaintaining skills on patients is no longer acceptable when alternatives exist. Reduced working hours further limit opportunities for the traditional experiential learning of advanced procedural skills. Our surgical colleagues, faced with similar issues, have responded over the last few decades with extensive research and innovation aimed at optimising procedural performance and reducing error. Simulation and skills laboratories are now required by the Accreditation Council for Graduate Medical Education American (ACGME) and the research questions have moved from does simulation work to defining the elements of skills training and pre-procedure preparation that work best in different contexts. However, even our surgical colleagues have struggled to integrate simulation-based skills programs into the regular training environment. The pre-procedural warm-up, by bringing simulators into the theatre suite,may help to embed simulation practice into the standard preparation for surgery. A further approach, also the subject of recent intense research activity, is mental imagery, a structured process of mental rehearsal prior to the procedure. Warm-up and mental imagery are well established in sports and the arts prior to a performance, and increasing evidence supports their value in surgery in improving performance and reducing procedural error. In this issue, Samuelson and colleagues describe a warm-up for fibre-optic intubation (FOI) for anaesthesia trainees. They randomised subjects to a control group with no warm-up and an intervention group who undertook a 5-minute warm-up using a series of cases of varying difficulty on a virtual reality bronchoscopy simulator. Subsequent performance of asleep FOI in healthy patients with no anticipated airway difficulties showed significantly better performance in the warm-up group. I could find no other studies reporting pre-procedural warm-up in anaesthesia and only one onmental imagery. Of relevance,Wright and colleagues reported that the rates of errors, such as administering the wrong medication or blood, inadequate depth of anaesthesia, and oesophageal intubation, decrease after the first operations of the day, suggesting that anaesthetists’ performance may improve after a period of warm-up. I undertook a Medline search of the literature on warm-up and mental imagery for procedural skills and provide here a narrative review with reference to potential application in anaesthesia. Pre-procedural warm-up