Qual Saf Health Care
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Qual Saf Health Care · Jun 2005
Comparative StudyCrisis management during anaesthesia: the development of an anaesthetic crisis management manual.
All anaesthetists have to handle life threatening crises with little or no warning. However, some cognitive strategies and work practices that are appropriate for speed and efficiency under normal circumstances may become maladaptive in a crisis. It was judged in a previous study that the use of a structured "core" algorithm (based on the mnemonic COVER ABCD-A SWIFT CHECK) would diagnose and correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining 40%. It was recommended that specific sub-algorithms be developed for managing the problems underlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms were therefore developed for these problems so that they could be checked for applicability and validity against the first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS). ⋯ The 24 sub-algorithms developed form the basis for developing a rational evidence-based approach to crisis management during anaesthesia. The COVER component has been found to be satisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for several years. It would now be desirable for carefully designed simulator based studies, using naive trainees at the start of their training, to systematically examine the merits and demerits of various aspects of the sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, as decision aids to support and back up clinicians' natural responses to a crisis when all is not progressing as expected.
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Anaphylactic and anaphylactoid reactions during anaesthesia are a major cause for concern for anaesthetists. However, as individual practitioners encounter such events so rarely, the rapidity with which the diagnosis is made and appropriate management instituted varies considerably. ⋯ An increased awareness of the diverse clinical manifestations of allergy seen in anaesthetic practice, together with the adoption of a structured approach to management should improve and standardise the treatment and improve follow up of patients suspected of having suffered a significant allergic reaction under anaesthesia.
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Qual Saf Health Care · Jun 2005
Multicenter Study Comparative StudyMedication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France.
Previous studies have identified medication errors in preparing and administering intravenous medicines of 13-84% in hospitals in individual countries. ⋯ Uncontrolled risks in the intravenous systems studied were observed in all three countries. Intravenous therapy must be regarded as a high risk activity where the use of risk management procedures to minimise risk to patients is seen as a high priority by all those involved with these duties. There is a requirement to develop better national (possibly international) procedures for safe intravenous practice.
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Regional anaesthesia is widely used and has been considered to pose few risks once the block is established. However, life threatening problems can occur both during the establishment and maintenance phases of a regional block which require prompt recognition and management. ⋯ Based on an analysis of 252 incidents, the core algorithm and the regional anaesthesia sub-algorithm, properly applied, would lead to swift recognition and appropriate management of problems arising in association with regional anaesthesia.
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Pneumothorax is a potentially dangerous condition which may arise unexpectedly during anaesthesia. The diagnosis is one of exclusion, as initial changes in vital signs (cardiorespiratory decompensation and difficulty with ventilation) are non-specific, and other causes of such changes are more common, whereas local signs may be difficult to elicit, especially without full access to the chest. ⋯ Any pneumothorax may become a dangerous tension pneumothorax with the application of positive pressure ventilation. Limited access to the chest during anaesthesia may compromise the diagnosis. Recognition of any preoperative predisposition to a pneumothorax (for example, iatrogenic or traumatic penetrating procedures around the base of the neck) and close communication with the surgeon are important. Aspiration diagnosis in suspected cases and correct insertion of a chest drain are essential for the safe conduct of anaesthesia and surgery.