Improving the governance of patient safety in emergency care: a systematic review of interventions

OBJECTIVES: To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.DESIGN: A systematic review of the literature.METHODS: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings.RESULTS: Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively.CONCLUSIONS: Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base

Anxiolytics, sedatives and hypnotics

Anxiolytics and sedatives are used in current anaesthetic practice for two main reasons: for anxiolysis before surgery and as adjuvants during anaesthesia. A wide choice of agents are available. Their safety profile is dependent on their pharmacokinetic and pharmacodynamic profiles, patient comorbidity and the experience of the clinician using them. All sedative drugs have the potential to cause severe respiratory depression, and hence they should only be used with standard physiological cardiorespiratory monitoring. This is especially true of procedural sedation administered by non-anaesthetists in remote locations. Drugs used for anaesthesia vary in their pharmacology, but have broadly similar clinical effects. The choice of drug is usually a matter of individual preference, although pharmacokinetic and pharmacodynamic parameters do influence the selection of anaesthetic agents, especially in day case surgery. Most intravenous agents are thought to alter consciousness by an effect at the γ-aminobutyric acid type A (GABAA) or N-methyl-D-aspartate (NMDA) receptors or both. Our understanding of the mechanisms of action of anaesthetic drugs is incomplete, not least because of a lack of understanding of consciousness. Several theories have been proposed over the last century, but none of them has managed to comprehensively elucidate the processes involved. There is now a sense of expectation that with the use of modern imaging techniques, anaesthetic drug action can be better understood, and that this may help in our understanding of consciousness and cognitive functions

Orthostatic blood pressure recovery in older males using alpha-blockers for lower urinary tract symptoms, an explorative study in a urology outpatient clinic

What is known and objective Alpha-blockers have been associated with orthostatic hypotension (OH). We aimed to assess the prevalence of OH measured with beat-to-beat blood pressure monitoring in older male outpatients who used alpha-blockers for lower urinary tract symptoms (LUTS). In addition, we investigated associations of OH with duration of alpha-blocker use, concomitant medication use and comorbidity. Methods Cross-sectional explorative study in a urology outpatient clinic. Older white males >= 65 years using alpha-blockers for LUTS were included. Blood pressure responses to standing up from supine were recorded using a validated beat-to-beat blood pressure device (Finapres). Prevalence rates were derived from the beat-to-beat data to include OH measured between 60-110 s (OH), impaired recovery OH at 40 s (OH[40]), initial OH (IOH) and normal orthostatic response. Subgroups were defined based on duration of alpha-blocker use, polypharmacy, and Charlson comorbidity index (CCI), to obtain relative risks. Results and discussion Sixty-five patients were included. Median age was 75 years (range 65-92). The prevalence of OH was 7.7% (n = 5). The prevalence of OH(40) was 16.9% (n = 11) and of IOH 38.5% (n = 25). Thirty-six patients (55.4%) had a normal orthostatic response. The relative risk of OH for the subgroup using >=$$\ge$$ 10 medications (n = 13) was 6.0 (95%CI 1.1-32.3). For the subgroup with multimorbidity (CCI >= 3, n = 11) this was 7.4 (95%CI 1.4-39.0). Recent initiation of alpha-blocker use