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      The role of the anesthesiologist in perioperative patient safety

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          Abstract

          Purpose of review

          Despite the benefits of rapidly advancing therapeutic and diagnostic possibilities, the perioperative setting still exposes patients to significant risks of adverse events and harm. Anesthesiologists are in midstream of perioperative care and can make significant contributions to patient safety and patient outcomes. This article reviews recent research results outlining the current trends of perioperative patient harm and summarizes the evidence in favor of patient safety practices.

          Recent findings

          Adverse events and patient harm continue to be frequent in the perioperative period. Adverse events occur in about 30% of hospital admissions, are associated with higher mortality, and may be preventable in more than 50%. Evidence-based recommendations are available for many patient safety issues. No magic bullet practices exist, but promising targets include the prevention and limitation of perioperative infections and of complications of airway and respiratory management, the maintenance of achieved safety standards, the use of checklists, and others.

          Summary

          Current research provides growing evidence for the effectiveness of several patient safety practices designed to prevent or diminish perioperative adverse events and patient harm. Future investigations will hopefully fill the numerous persisting knowledge gaps.

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          Most cited references62

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          Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.

          This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events. Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgical airway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. An expert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated a denominator of 2.9 million general anaesthetics annually. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38-54] or one per 22,000 (95% CI 1 per 26-18,000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8-8.3): one per 180,000 (95% CI 1 per 352-120,000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is 'room for improvement'.
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            Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.

            Intraoperative hypotension may contribute to postoperative acute kidney injury (AKI) and myocardial injury, but what blood pressures are unsafe is unclear. The authors evaluated the association between the intraoperative mean arterial pressure (MAP) and the risk of AKI and myocardial injury.
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              A new, evidence-based estimate of patient harms associated with hospital care.

              Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011. A literature review identified 4 limited studies that used primarily the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient. Ultimately, a physician must concur on the findings of an adverse event and then classify the severity of patient harm. Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm. The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients' voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.
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                Author and article information

                Journal
                Curr Opin Anaesthesiol
                Curr Opin Anaesthesiol
                COANA
                Current Opinion in Anaesthesiology
                Lippincott Williams & Wilkins
                0952-7907
                1473-6500
                December 2014
                06 November 2014
                : 27
                : 6
                : 649-656
                Affiliations
                [a ]Institute of Anesthesia and Intensive Care, Hirslanden Clinic, Zurich
                [b ]Department of Anesthesia and Intensive Care Medicine, Regional Hospital Maennedorf, Maennedorf, Switzerland
                [c ]Department of Anesthesiology, Perioperative Medicine, and Critical Care Medicine, Paracelsus Medical University, Salzburg, Austria
                Author notes
                Correspondence to Dr med. Johannes Wacker, Consultant Anesthesiologist, Institute of Anesthesia and Intensive Care, Hirslanden Clinic, Witellikerstrasse 40, CH-8032, Zurich, Switzerland. Tel: +41 44 387 2365; fax: +41 44 387 3885; e-mail: johannes.wacker@ 123456hirslanden.ch
                Article
                00015
                10.1097/ACO.0000000000000124
                4232292
                25233191
                981f72f1-927d-428e-b93c-9e0b33e114b0
                © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0

                History
                Categories
                TECHNOLOGY, EDUCATION AND SAFETY: Edited by Sven Staender
                Custom metadata
                TRUE

                adverse events,anesthesia,patient safety,perioperative management,safety practice

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