Perioperative and anesthetic deaths: toxicological and medico legal aspects

Background: Anesthesia has become safer during decades, though there is still a preventable mortality; the complexity of medical and surgical interventions, increasingly older and sicker patients, has created a host of new hazards in anesthesiology. In this paper, some of these perioperative (PO) fatal adverse events are investigated in terms of health responsibility. Selective literature research in several data bases, concerning perioperative and anesthetic deaths and medical responsibility, was performed. Main text: A generally accepted definition of the anesthesia and perioperatory-related death still remains one of the major concerns in forensic pathology, and the terms “operative deaths” and “anesthetic deaths” are usually applied inaccurately within the medico-legal literature. Such events involve comprehensively PO fatalities and allow for subtle separation of natural and unnatural death, at least from the prospective of forensic pathology. Iatrogenic deaths in this field can be separated into some major categories, as attributable to previous patient’s unfavorable conditions or depending from surgical procedure per se (such as PO cardiac and cerebrovascular events). In this review, the authors carried out syntheses of specific research areas regarding epidemiology, complications of general and spinal anesthetic, failure in airway management and patient’s circulatory homeostasis, and adverse drugs reactions; analysis considering the challenge of anesthetic-related mortality, epidemiology and classifications, by indicating causal chain of death, in respect of both contributing and associated anesthetic and surgery facts. Conclusions: Perioperative quality control programs and its relevance for medico-legal evaluation are emphasized as, although mortality rates have decreased worldwide over the last decades, however, preventable drug-related deaths still happen. Such fatal events have to be considered within the field of forensic pathology experts, with regard of malpractice claims, to implement a strategy for preventing potentially fatal complications

Patient safety in Europe: medication errors and hospital-acquired infections

The Report was commissioned by the European Federation of Nurses Associations (EFN) in November 2007 in order to support its policy statements on Patient Safety (June 2004). In that statement the EFN declares its belief that European Union health services should operate within a culture of safety that is based on working towards an open culture and the immediate reporting of mistakes; exchanging best practice and research; and lobbying for the systematic collection of information and dissemination of research findings. This Report adressess specifically the culture of highly reliable organisations using the work of James Reason (2000). Medication errors and hospital-acquired infections are examined in line with the Reprt´s parameters and a range of European studies are used as evidence. An extensive reference list is provided that allows EFN to explore work in greater detail as required

A Comparison of the Features and Functions Available in Electronic Health Records

The Institute of Medicine (IOM) (2007) estimates that medical errors transpire at a rate of 1.5 million per year. The IOM (2000), approximates 7,000 deaths per year are related to preventable medication errors, which are the leading cause of medical errors. Adverse drug events (ADE) occur due to medication errors, which are 100% preventable. Annually, approximately $21 billion dollars are spent to care for patients’ who experience ADE due to medication errors (IOM, 2007). This doctoral project evaluates the current features and available functions for pediatric medication administration within the electronic health record (EHR). This comparison explored the EHR functionalities across all pediatric services and compared those tools to the features utilized in pediatric anesthesia. The electronic charting systems evaluated include: neonatal intensive care unit (NICU), emergency department (ED), post anesthesia care unit (PACU), operating room (OR), nursery, pre-operative, general pediatric floor and anesthesia departments. The EHR evaluation determined the department with the greatest differences in the EHR and medication administration record (MAR) is the anesthesia environment. The pediatric weight-based medication dosage was available for all other departments; therefore the same feature should be accessible to anesthesia providers

Best Practice Guideline: Color-Coded Syringe Labeling of Anesthesia Induction Drugs

The purpose of this Doctor of Nursing Practice (DNP) project was to propose a safe practice recommendation through the utilization of evidence-based research on the use of the standardized color-coded labeling guidelines for user-filled syringes in anesthesia practice. The primary objective of standardized color-coded labeling is to improve patient safety by facilitating the identification of user-prepared medication syringes. Guidelines developed by the American Society for Testing and Materials International (ASTM) are endorsed by the American Society of Anesthesiologists (ASA) and aim to increase quality care and patient safety. Currently, there is no standardized color-coded labeling system in anesthesia practice that is universally implemented and enforced by accrediting organizations. These inconsistencies can lead to medication errors and adverse patient outcomes. Ubiquitous adoption of a standardized color-coded labeling system is capable of increasing patient safety and decreasing the incidence of mediation errors through the facilitation of syringe recognition by anesthesia providers in the perioperative period. The guidelines developed by ASTM International were used to develop a safe practice recommendation. A survey was sent to current junior and senior students at The University of Southern Mississippi (USM) as well as nurse anesthesia faculty at The University of Southern Mississippi. Data and feedback from the survey was analyzed for further development of the safe practice recommendation

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Usefulness of Medication Scanners in Clinical Practice: A Systematic Review

Thousands of people die each year due to preventable medication errors. Barcode medication administration (BCMA) systems can reduce medication errors at the point of care, thus increasing patient safety. The purpose of the project was to gather evidence regarding BCMA usefulness in reducing medication errors. Kurt Lewin\u27s 3-step change theory was used to guide this project. The nature of this project was a systematic review of the literature pertaining to the effectiveness of using BCMA systems to reduce medication errors in at the point of care in the hospital setting. The Johns Hopkins nursing evidence-based practice model and tool kit was used to evaluate each article. The review comprised one systematic review, one integrative review, and 6 before-and-after observational studies. The results of each study indicated that the use of a BCMA system could reduce medication errors but not completely eliminate them. The findings of this project contribute evidence that BCMA systems can assist the clinician in safely administering medication. Dissemination of the evidence will contribute to a positive change by promoting greater understanding of the effectiveness of using BCMA systems in all areas that administer medication

The effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review

Objectives To synthesize the best available evidence on the safety and effectiveness of pharmacist prescribing on patient outcomes in patients who present to hospital. Background Pharmacist prescribing is legal in many countries. Different models of prescribing include dependent, collaborative and independent. Existing reviews of pharmacist prescribing focus on studies in the community setting, or both community and hospital settings. Other reviews focus on descriptions of current practice or perspectives of clinicians and patients on the practice of pharmacist prescribing. A systematic review on the effects of pharmacist prescribing on patient outcomes in the hospital has not been previously undertaken and is important as this practice can help ease the burden on the healthcare system. Inclusion criteria Studies with controlled experimental designs comparing pharmacist prescribing to medical prescribing in the hospital setting were included in the review. Primary outcomes of interest included clinical outcomes such as therapeutic failure or benefit, adverse effects and morbidity or mortality. Secondary outcomes included error rates in prescriptions, medication omissions on the medication chart, time or proportion of International Normalized Ratios in therapeutic range, time to reach therapeutic range and patient satisfaction. Methods A comprehensive three-step search strategy was utilized. The search was conducted in January 2017 in eight major databases from database inception. Only studies in English were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection and data extraction was used. Narrative synthesis was performed due to heterogeneity of the studies included in the review. Results The fifteen included studies related to dependent and collaborative prescribing models. In four studies that measured clinical outcomes, there was no difference in blood pressure management between pharmacists and doctors while patients of pharmacist prescribers had better cholesterol levels (mean difference in low density lipoprotein of 0.4 mmol/L in one study and 1.1 mmol/L in another; mean difference in total cholesterol of 1.0 mmol/L) and blood sugar levels (mean difference of fasting blood sugar levels of 15 mg/dL, mean difference of glycosylated hemoglobin of 2.6 %). In two studies, pharmacists were better at adhering to warfarin dosing nomograms than doctors (average of 100% versus 62% compliance). In six studies, when prescribing warfarin according to dosing nomograms, equivalent numbers or more patients were maintained in therapeutic range by pharmacist prescribers compared to doctors. The incidence of adverse effects related to anticoagulant prescribing was similar across arms but all six studies were underpowered to detect this outcome. Three studies found that pharmacist prescribers made less prescribing errors (20 to 25 times less errors) and omissions (three to 116 times less omissions) than doctors when prescribing patients’ usual medications on admission to hospital or in the pre-operative setting. Two studies reported that patients were as satisfied with the services provided by pharmacist prescribers as with doctors. Conclusions This review provides low to moderate evidence that pharmacists can prescribe to the same standards as doctors. Compared to doctors, pharmacists are better at adhering to dosing guidelines when prescribing by protocol and make significantly less prescribing errors when charting patients’ usual medications on admission to hospital.Thesis (M.Clin.Sc.) -- University of Adelaide, Joanna Briggs Institute, 201

Actionable Patient Safety Solution (APSS) #3D: Pediatric Adverse Drug Events

This report presents a plan of action for introducing a program to reduce the incidence of pediatric adverse drug events (pADEs) and harm ... [that] combine[s] leadership strategies, software (healthcare IT), hardware (drug compounding systems, drug delivery technology, and physiological monitoring systems), and most importantly people (changes in clinical practice, protocols and education) to protect pediatric patients

Using a Cost Benefit Analysis to Support the Development of a Comprehensive Business Model for a Pre-Filled, Pre-Labeled, Pre-Diluted, Sterilely Packaged, Ready-to-Use, Syringe-Based Anesthesia Delivery System

The foundation of Certified Registered Nurse Anesthetists’ (CRNAs) entire profession is built on the ability to provide anesthetic services using a variety of medications in the safest, most efficient, cost-effective way possible. The purpose of this capstone is to address, via a comprehensive cost benefit analysis, whether pre-filled syringe drug trays are a more cost-effective way to address problems as compared to vial-filled drug trays and to implement the necessary transitions in order to improve outcomes. There are a number of identifiable problems related to anesthesia medication delivery via vial-filled medication, including increased cost of healthcare, decreased patient safety to provider inconvenience, increased medication errors, and increased contamination. The method of medication delivery has gained the attention of significant governing bodies such as the Joint Commission of Healthcare Organizations (JCAHO), Centers for Disease Control (CDC), and American Association of Nurse Anesthetists (AANA), just to name a few. The best methods for change were evaluated in order to facilitate the most optimal quality improvement. According to the AANA, “the available information is sufficient to promote the implementation of pre-filled or premixed syringes in anesthesia departmentsto reduce the number of adverse drug events (ADEs) and become compliant with the Joint Commission, and Institute of Medicine” (Brown, 2014, pp. 465-469). The future change in anesthesia drug delivery is undeniable, and the data provide clearly defined recommendations and guidelines supporting the use of pre-filed syringes. Providing medications in pre-filled syringes would reduce medication errors and treatment delays, improve patient safety, and effectively meet the expectations, recommendations, and guidelines of governing entities (Fahimi et al., 2008). “When you look at the impact of the initiative on quality and safety for the patients, it’s [just] what’s right to do” (Blum, 2013, p. 3)