QUALITY & SAFETY: أغسطس 2012

الأربعاء، 8 أغسطس 2012

Failures in communication and information transfer across the surgical care pathway: interview study

Failures in communication and information transfer across the surgical care pathway: interview study -- Nagpal et al. -- BMJ Quality and Safety Search the BMJ BMJ BMJ Journals BMJ Careers BMJ Learning Evidence Centre doc2doc BMJ Group

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BMJ Qual Saf doi:10.1136/bmjqs-2012-000886 Original research Failures in communication and information transfer across the surgical care pathway: interview study

OPEN ACCESS Kamal Nagpal, Sonal Arora, Amit Vats, Helen W Wong, Nick Sevdalis, Charles Vincent, Krishna Moorthy

Centre for Patient Safety and Surgical Quality, Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK Correspondence to Sonal Arora, Department of Biosurgery and Surgical Technology, Imperial College London, 10th floor, QEQM, St Mary's Hospital, South Wharf Road, London W2 1NY, UK; sonal.arora06{at}imperial.ac.uk Contributors KN, KM, NS, CV were involved in conception and design, analysis and interpretation of data. KN, HW, SA, AV were involved in acquisition, analysis and interpretation of data. SA, KN, AV, HWW drafted the initial article. KM, NS, CV revised it critically for important intellectual content. KN, SA, AV, HWW, NS, CV, KM had final approval of the version to be published.

Accepted 10 April 2012 Published Online First 7 July 2012 Abstract Background and Objectives Effective communication is imperative to safe surgical practice. Previous studies have typically focused upon the operating theatre. This study aimed to explore the communication and information transfer failures across the entire surgical care pathway.

Methods Using a qualitative approach, semi-structured interviews were conducted with 18 members of the multidisciplinary team (seven surgeons, five anaesthetists and six nurses) in an acute National Health Service trust. Participants' views regarding information transfer and communication failures at each phase of care, their causes, effects and potential interventions were explored. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Sampling ceased when categorical and theoretical saturation was achieved.

Results Preoperatively, lack of communication between anaesthetists and surgeons was the most common problem (13/18 participants). Incomplete handover from the ward to theatre (12/18) and theatre to recovery (15/18) were other key problems. Work environment, lack of protocols and primitive forms of information transfer were reported as the most common cause of failures. Participants reported that these failures led to increased morbidity and mortality. Healthcare staff were strongly supportive of the view that standardisation and systematisation of communication processes was essential to improve patient safety.

Conclusions This study suggests communication failures occur across the entire continuum of care and the participants opined that it could have a potentially serious impact on patient safety. This data can be used to plan interventions targeted at the entire surgical pathway so as to improve the quality of care at all stages of the patient's journey.

Communication information transfer handover interview surgery checklists patient safety root cause analysis risk management Footnotes Funding The research described here was supported by the National Institute of Health Research (NIHR) and the UK Engineering and Physical Sciences Research Council (EPSRC).

Competing interests None.

Ethics approval The project protocol was submitted to the National Research Ethics Service (Joint UCL/UCLH Committees on the Ethics of Human Research). They felt it was a ‘service evaluation’ study so did not require ethical approval. REC reference number: 08/H0715/112.

Provenance and peer review Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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OPEN ACCESS This Article Abstract Full text PDF Services Email this link to a friend Alert me when this article is cited Alert me if a correction is posted Alert me when eletters are published Article Usage Statistics Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request permissions Add to portfolio Responses Submit a response No responses published Citing articles Load citing article information Citing articles via Scopus Google Scholar Articles by Nagpal, K. Articles by Moorthy, K. Search for related content PubMed PubMed citation Articles by Nagpal, K. Articles by Moorthy, K. Related Content Unlocked Load related web page information Social bookmarking Add to CiteULike

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Crisis management during anaesthesia: laryngospasm

The international journal of healthcare improvement Qual Saf Health Care 2005;14:e3 doi:10.1136/qshc.2002.004275 T Visvanathan1, M T Kluger2, R K Webb3, R N Westhorpe4

1Staff Specialist, Department of Anaesthesia, The Queen Elizabeth Hospital, Woodville, South Australia, Australia

2Senior Staff Specialist, Department of Anaesthesiology and Perioperative Medicine, North Shore Hospital, Auckland, New Zealand

3Senior Staff Specialist; Department of Anaesthesia and Intensive Care, The Townsville Hospital, Douglas, Queensland, Australia

4Deputy Director, Department of Paediatric Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Victoria, Australia Correspondence to:? Professor W B Runciman? President, Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia 5001, Australia; researchapsf.net.auBackground: Laryngospasm is usually easily detected and managed, but may present atypically and/or be precipitated by factors which are not immediately recognised. If poorly managed, it has the potential to cause morbidity and mortality such as severe hypoxaemia, pulmonary aspiration, and post-obstructive pulmonary oedema.

Objectives: To examine the role of a previously described core algorithm “COVER ABCD–A SWIFT CHECK”, supplemented by a specific sub-algorithm for laryngospasm, in the management of laryngospasm occurring in association with anaesthesia.

Methods: The potential performance of this structured approach for the relevant incidents amongst 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 189 reports of laryngospasm among the first 4000 incidents reported to AIMS. These were extracted and analysed. In 77% of cases laryngospasm was clinically obvious, but 14% presented as airway obstruction, 5% as regurgitation or vomiting, and 4% as desaturation. Most were precipitated by direct airway stimulation (airway manipulation, regurgitation, vomiting, or blood or secretions in the pharynx), but patient movement, surgical stimulus, irritant volatile agents, and failure to deliver the anaesthetic were also precipitating factors. Desaturation occurred in over 60% of cases, bradycardia in 6% (23% in patients aged <1 year), pulmonary oedema in 4%, and pulmonary aspiration in 3%. It was considered that, correctly applied, the combined core algorithm and sub-algorithm recommended for the diagnosis and management of laryngospasm would have led to earlier recognition of the problem and/or better management in 16% of cases.

Conclusion: Laryngospasm may present atypically and, if not promptly managed effectively, may lead to morbidity and mortality. Although usually promptly recognised and appropriately managed, the use of a structured approach is recommended. If such an approach had been used in the 189 reported incidents, earlier recognition and/or better management may have occurred in 16% of cases.

This study was coordinated by The Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia 5001, Australia.

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Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study

Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study -- Hogan et al. -- BMJ Quality and Safety Search the BMJ BMJ BMJ Journals BMJ Careers BMJ Learning Evidence Centre doc2doc BMJ Group

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BMJ Qual Saf doi:10.1136/bmjqs-2012-001159 Original research Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study

OPEN ACCESS Helen Hogan1, Frances Healey2, Graham Neale3, Richard Thomson4, Charles Vincent3, Nick Black1

1Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK

2National Patient Safety Agency, London, UK

3Clinical Safety Research Unit, Imperial College, London, UK

4Institute of Health and Society, University of Newcastle, Newcastle upon Tyne, UK Correspondence to Dr Helen Hogan, Clinical Lecturer in UK Public Health, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; helen.hogan{at}lshtm.ac.uk Contributors RT was responsible for the original study idea. All authors contributed to the design of the study and the review forms. HH and GN were responsible for recruiting and training reviewers. HH was responsible for data collection and analysis and, with GN, provided additional support to reviewers. All authors contributed to data interpretation. HH and NB drafted the manuscript and all authors contributed to its revision. HH is guarantor.

Accepted 21 May 2012 Published Online First 7 July 2012 Abstract Introduction Monitoring hospital mortality rates is widely recommended. However, the number of preventable deaths remains uncertain with estimates in England ranging from 840 to 40?000 per year, these being derived from studies that identified adverse events but not whether events contributed to death or shortened life expectancy of those affected.

Methods Retrospective case record reviews of 1000 adults who died in 2009 in 10 acute hospitals in England were undertaken. Trained physician reviewers estimated life expectancy on admission, to identified problems in care contributing to death and judged if deaths were preventable taking into account patients' overall condition at that time.

Results Reviewers judged 5.2% (95% CI 3.8% to 6.6%) of deaths as having a 50% or greater chance of being preventable. The principal problems associated with preventable deaths were poor clinical monitoring (31.3%; 95% CI 23.9 to 39.7), diagnostic errors (29.7%; 95% CI 22.5% to 38.1%), and inadequate drug or fluid management (21.1%; 95% CI 14.9 to 29.0). Extrapolating from these figures suggests there would have been 11?859 (95% CI 8712 to 14?983) adult preventable deaths in hospitals in England. Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities judged to have had less than 1 year of life left to live.

Conclusions The incidence of preventable hospital deaths is much lower than previous estimates. The burden of harm from preventable problems in care is still substantial. A focus on deaths may not be the most efficient approach to identify opportunities for improvement given the low proportion of deaths due to problems with healthcare.

Hospital mortality patient safety medical errors adverse events Footnotes Funding The funders of the study, the National Institute of Health Research, Research for Patient Benefit Programme had no role in study design, data collection, data analysis, data interpretation, or composition of the report. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Competing interests All authors have completed the unified competing interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that neither authors nor their family relations have a financial or non-financial interest that might be relevant to the submitted work.

Patient consent Patients in the study were deceased. Section 251 of the National Health Service Act 2006 for the use of patient identifiable information without consent was gained.

Ethics approval Ethics approval was received from the National Hospital for Neurology and Neurosurgery and the Institute of Neurology joint multi-centre research ethics committee and research governance approval was granted by each participating Trust.

Provenance and peer review Not commissioned; internally peer reviewed.

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OPEN ACCESS This Article Abstract Full text PDF Services Email this link to a friend Alert me when this article is cited Alert me if a correction is posted Alert me when eletters are published Article Usage Statistics Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request permissions Add to portfolio Responses Submit a response No responses published Citing articles Load citing article information Citing articles via Scopus Google Scholar Articles by Hogan, H. Articles by Black, N. Search for related content PubMed PubMed citation Articles by Hogan, H. Articles by Black, N. Related Content Unlocked Load related web page information Social bookmarking Add to CiteULike

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