Improving patient safety in medicine: is the model of anaesthesia care enough?

Avoiding iatrogenic adverse outcomes and providing safe care to patients is a priority in modern healthcare systems. Because anaesthetic practice is inherently risky, the specialty has developed a broad range of strategies to minimise human error and risk for patients. These are part of a hierarchical model developed by industrial safety experts to minimise risk. It is known as the safety hierarchy model. This review will describe the use of this model in anaesthesia and show why the specialty is often cited as a role model for patient safety improvement. It will also explore the extension of the model to other specialties and analyse its intrinsic limitations due to new challenges to patient safety: teamwork and communication issues. These will conclude the review

Measuring Patient Safety: Methods for Anesthesia Care

Avoiding iatrogenic adverse outcomes and providing safe care to patients is a priority in modern healthcare systems. In anaesthesia, measuring patient safety has been a matter of attention since the beginning of the speciality. The number of studies looking at anesthesia-related mortality-morbidity, adverse events and critical incidents reporting is substantial. These traditional patient safety measurement methods have significant limitations. They are qualitative by nature and often lack specificity for patient safety issues. Alternative approaches such as automated adverse events measurement in electronic records and safety culture questionnaires have been developed to overcome traditional methods’ weaknesses. However these lack validity and specificity for anaesthetic practice. Clinical indicators offer promise as they are specifically designed to measure non quantifiable concepts such as patient safety. However, at this stage, the number of clinical indicators validated for safety measurement in anaesthesia is limited. Further developments are required before indicators can be used on a large scale to measure safety of anaesthetic practice. Despite inherent weaknesses of existing methods, figures show that there is a clear decrease in the number of major accidents and severe complications associated with anaesthesia. Nevertheless, although anaesthesia can claim successes in reducing the number of major adverse outcomes, anaesthesia-related morbidity still remains significant. Poor teamwork and organisational failures play an important role into these complications. Improving communication and team coordination are the new challenges anaesthesia is facing. However to address these issues, being able to reliably measure patient safety in anaesthesia remains a priority

Leçons tirées des évènements indésirables en anesthésie

La pratique anesthésique est intrinsèquement risquée. L’analyse de la mortalité et la morbidité associées à la pratique de l’anesthésie a montré que des améliorations substantielles avaient été obtenues au cours des 50 dernières années. Ces résultats sont le fruit de multiples innovations telles que l’introduction de la classification ASA, l’évaluation systématique des comorbidités, les codes couleurs pour les fluides administrés, le monitorage par oxymétrie pulsée de la saturation artérielle en oxygène et celui de la profondeur d’anesthésie, les salles de réveil pour n’en citer que quelques unes. Toutefois, le niveau de validité scientifique sur lequel ces innovations s’appuient est très variable. Le niveau de preuve de l’efficacité de la mesure de la profondeur d’anesthésie pour limiter la mémorisation est élevé (méta-analyses, études randomisée contrôlées). En revanche l’intérêt des codes couleurs pour limiter le risque d’anoxie par erreur d’administration de gaz inhalés est mal démontré mais tombe sous le sens. Néanmoins, le bon sens n’exclut pas que l’on évalue rigoureusement les innovations présentées comme pouvant améliorer la sécurité des patients.Anesthetic practice is inherently risky. Adverse events associated with anaesthetic practice have been evaluated for a long time. A significant decrease in anaesthesia-related mortality and morbidity has been achieved over the last 50 years. This improvement is the result of multiple innovations such as the use of ASA classification, systematic preoperative assessment of comorbidities, color codes for oxygen and nitrous oxide cylinders, pulsoxymeters, postanaesthesia care units and devices measuring depth of anesthesia. However, the value of the evidences supporting the use of these innovations is highly variable. If the level of evidences demonstrating the effectiveness of bispectral index and other measures of the depth of anesthesia to prevent awareness is high, the evidence supporting color coding of oxygen and nitrous oxide cylinders to reduce the risk of anoxia is low. These innovations are mainly supported by common sense. However, many innovations and procedures should be more systematically assessed in order to discriminate effective from ineffective practices or devices, for the best benefit of patients

Scores for preoperative risk evaluation of postoperative mortality

Preoperative risk evaluation scores are used prior to surgery to predict perioperative risks. They are also a useful tool to help clinicians communicate the risk–benefit balance of the procedure to patients. This review identifies and assesses the existing preoperative risk evaluation scores (also called prediction scores) of postoperative mortality in all types of surgery (emergency or scheduled) in an adult population.We systematically identified studies using the MEDLINE, Ovid EMBASE and Cochrane databases and published studies reporting the development and validation of preoperative predictive scores of postoperative mortality. We assessed usability, the level of evidence of the studies performed for external validation, and the predictive accuracy of the scores identified. We found 26 scores described within 60 different reports. The most suitable scores with the highest validity identified for anaesthesia practice were the Preoperative Score to Predict Postoperative Mortality (POSPOM), the Universal ACS NSQIP surgical risk calculator (ACS-NSQUIP), the Clinical Frailty Scale (CFS) and the American Society of Anesthesiologists Physical Status (ASA-PS) classification system. While other scores identified in this review could also be endorsed, their level of validity and generalizability to the general surgical population should be carefully considered.</p

Is ‘Crew Resource Management' an Alternative to Procedure-Based Strategies to Improve Patient Safety in Hospitals?

In hospitals, procedure-based strategies can be defined as the systematic use of procedures or series of steps followed in a regular order to complete a task. This definition covers a mix of several different mechanisms aimed at controlling, organizing and standardizing clinical work processes. This chapter analyses mechanisms to show how procedures are implemented to control and standardize healthcare professional's clinical activities and improve patient safety. Crew Resource Management (CRM) is designed to improve the way healthcare professional's think and act during crisis or routine management of patients by improving communication and teamwork. The key concept of CRM is: 'Training crews to reduce "pilot errors" by making better use of the human resources on the flight deck'. This case report shows that CRM-based training programmes developed within the aviation community can be implemented in hospitals and are an effective way to improve teamwork and ultimately quality and safety of care