A tragic death: a time to blame or a time to learn?

W.B. Runciman and A. Merr

Improving patients' safety by gathering information - Anonymous reporting has an important role

Bill Runciman, Alan Merry and Alexander McCall Smit

Crisis management during anaesthesia: difficult intubation

BACKGROUND: Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. OBJECTIVES: To examine the role of a specific sub-algorithm for the management of difficult intubation. METHODS: The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. CONCLUSION: The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient’s cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.A D Paix, J A Williamson and W B Runcima

Australian GP attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice

Abstract Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. We sought to explore general practitioner attitudes toward CPGs, in general and specifically for osteoarthritis (OA) with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 of a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided amongst respondents for short, 2-3 page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor with most respondents either not aware of it (30%: 95% CI 27% - 41%), had never used it (19%; 95% CI 12% - 29%), or rarely used it (34%; 95% CI 25% - 45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use. Key words: arthritis, primary care, evidence-based medicine, decision making Summary statement What is known about the topic? • Clinical practice guidelines (CPGs) can improve processes of care and health outcomes, however, there is often a gap between evidence-based recommendations for care and clinical practice. What does this paper add? • A better understanding of GP attitudes toward CPGs helps to explain potential barriers to the uptake of evidence-based practice and provides guidance on remedial action that may lead to better health outcomes.a National Health and Medical Research Council Program Grant (Australia, no.568612

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems

Objectives: To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare. Methods: Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology. Results: Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods. Conclusion: A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micromanaged and controlled through a hierarchy is preferable.5 page(s

Crisis management during anaesthesia: problems associated with drug administration during anaesthesia

© 2005 BMJ Publishing Group Ltd.BACKGROUND: Modern anaesthetic practice relies upon the administration of a wide range of potent drugs given by a variety of routes, at times in haste or under conditions of stress. Problems associated with drug administration make up the largest group of incidents reported during anaesthesia, with outcomes including major morbidity and death. It was decided to examine the role of a structured approach to the diagnosis and management of drug problems under anaesthesia. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for drug problems, in the detection and management of drug problems occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for the relevant incidents among the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performances as reported by the anaesthetists involved. RESULTS: Among the first 4000 reports received by AIMS there were 1199 reports which detailed 1361 incidents involving the use of drugs. Contributing factors named included errors of judgement (20%), lack of attention (17%), and drugs deemed to have been given in haste. Major morbidity or prolonged stay ensued in over one quarter of reports and 15 patients (1.25%) died. Drug overdose, side effects, and allergic reactions accounted for the majority of serious outcomes. CONCLUSION: It was judged that the use of the COVER–ABCD algorithm during the course of an anaesthetic, properly applied, would prevent many drug related incidents from occurring. The sub-algorithm presented here provides a systematic framework for detecting the causes of drug related incidents.A D Paix, M F Bullock, W B Runciman and J A Williamso

The pure effect of social preferences on regional location choices: The evolving dynamics of convergence to a steady state population distribution

This paper tracks the consequences of individuals’ desire to align their location with their social preferences. The social preference studied in the paper is distaste for relative deprivation, measured in a cardinal manner. Location is conceived as social space, with individuals choosing to relocate if, as a result, their relative deprivation will be reduced, holding their incomes constant. Conditions are provided under which the associated dynamics reaches a spatial steady state, the number of periods it takes to reach a steady state is specified, and light is shed on the robustness of the steady state outcome. By way of simulation it is shown that for large populations, a steady state of the relocation dynamics is almost always reached, typically in one period, and that cycles are more likely to occur when the populations’ income distributions are more equal

What unites Europe and what divides it? Solidarity and the European heritage reconsidered

Despite the on-set on new divisions, there is a strong case to be made for the view that ultimately Europe is more united than divided. There is still significant continuity with the post-war project of reconstruction and peace and that this common ground that constitutes the European heritage needs to be given greater recognition. One of the defining features of European self-understanding is opposition to war