Qual Saf Health Care
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In confronting an evolving crisis, the anaesthetist should consider the vascular catheter as a potential cause, abandoning assumptions that the device has been satisfactorily placed and is functioning correctly. ⋯ The approach has potential as an easily remembered and applied clinical tool to lead to early resolution of vascular access problems occurring during anaesthesia.
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Qual Saf Health Care · Jun 2005
Crisis management during anaesthesia: regurgitation, vomiting, and aspiration.
Regurgitation, vomiting and aspiration may occur unexpectedly in association with anaesthesia. "Aspiration/regurgitation" was ranked fifth in a large collection of previously reported incidents that arose during general anaesthesia. These problems are encountered by all practising anaesthetists and require instant recognition and a rapid, appropriate response. However, the diagnosis may not be immediately apparent as the initial presentation may vary from laryngospasm, desaturation, bronchospasm or hypoventilation to cardiac arrest. ⋯ Regurgitation and/or aspiration should always be considered immediately in any spontaneously breathing patient who suffers desaturation, laryngospasm, airway obstruction, bronchospasm, bradycardia, or cardiac arrest. Any patient in whom aspiration is suspected must be closely monitored in an appropriate perioperative facility, the acuity of which will depend on local staffing and workload. If clinical instability is likely to persist or if there are concerns by attending staff, the patient should be admitted to a high dependency unit or intensive care unit.
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Pulmonary oedema may complicate the perioperative period and the aetiology may be different from non-operative patients. Diagnosis may be difficult during anaesthesia and consequently management may be delayed. ⋯ Successful recognition and management of perioperative pulmonary oedema is likely with the application of the structured algorithm and specific sub-algorithm approach outlined in this study.
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Qual Saf Health Care · Jun 2005
Medication safety program reduces adverse drug events in a community hospital.
There is widespread interest in improving medication safety, particularly in the hospital setting. Numerous suggestions have been made as to how this should be done, but there is a paucity of data demonstrating the effectiveness of any of the interventions that have been proposed. ⋯ The implementation of a carefully planned series of low cost interventions focused on high risk medications, driven by information largely from internal event reporting, and designed to improve a hospital's medication safety leads to a significant decrease in patient harm.
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Qual Saf Health Care · Jun 2005
Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution.
To assess the effectiveness of the response of NHS hospital trusts to an alert issued by the National Patient Safety Agency designed to limit the availability of concentrated potassium chloride in hospitals in England and Wales, and to determine the nature of any unintended consequences. ⋯ The NPSA alert was effective and resulted in rapid development and implementation of local policies to reduce the availability of concentrated potassium chloride solutions. The success is likely to be partly due to the nature of the proposed changes and it cannot be assumed that future alerts will be equally effective. Continued vigilance will be necessary to help sustain the changes.