Artigo: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa,M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., and Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group*

N Engl J Med 2009;360:491-9

ABSTRACT

Background

Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.

Methods

Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization’s Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.

Results

The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).

Conclusions

Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

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Erros de prescrição de medicamentos em um hospital brasileiro

Eugenie Desiree Rabelo Néri, Paulo Gean Chaves Gadêlha, Sâmia Graciele Maia, Ana Graziela da Silva Pereira, Paulo César de Almeida, Carlos Roberto Martins Rodrigues, Milena Pontes Portela, Marta Maria de França Fonteles

Rev Assoc Med Bras 2011; 57(3):306-314

Objetivo: Identificar a prevalência de erros clinicamente significativos em prescrição de hospital universitário brasileiro, comparando sua ocorrência em 2003 e 2007.

Métodos: Análise das prescrições quanto às variáveis/grupo de variáveis como legibilidade, cumprimento de procedimentos legais e institucionais e análise de erros de prescrição.

Resultados: Quando calculadas as taxas de prevalência dos erros de prescrição clinicamente significativos, evidenciou-se uma redução estatisticamente significante [ano 2003 (29,25%), ano 2007 (24,20%); (z = 2,99; p = 0,03)], sendo refletido sobre a taxa de segurança [ano 2003 (70,75%), ano 2007 (75,80%); (z = 3,30; p = 0,0001].

Conclusão: Apesar de significativo, o aumento na taxa de segurança foi reflexo da redução quantitativa dos erros, não sendo observada diferença na gravidade dos mesmos entre os períodos. Nossos resultados sugerem que as medidas institucionais adotadas foram capazes de reduzir o número de erros, mas foram inefetivas na redução da gravidade dos mesmos.

Unitermos: Prescrições de medicamentos; erros de medicação; serviço hospitalar de educação.

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Artigo: Intubação Traqueal e o Paciente com o Estômago Cheio

Eduardo Toshiyuki Moro, Norma Sueli P. Módolo

Rev Assoc Med Bras 2009; 55(2): 201-6

RESUMO

A aspiração pulmonar do conteúdo gástrico, apesar de pouco frequente, exige cuidados especiais para sua prevenção. A depressão da consciência durante a anestesia predispõe os pacientes a esta grave complicação pela diminuição na função do esfíncter esofágico e dos reflexos protetores das vias aéreas. Guias de jejum pré-operatório elaborados recentemente sugerem períodos menores de jejum, principalmente para líquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratação, sem aumentar a incidência de aspiração pulmonar perioperatória.

O uso rotineiro de agentes que diminuem a acidez e volume gástrico parece estar indicado apenas para pacientes de risco. A intubação traqueal após indução anestésica por meio da técnica de sequência rápida está indicada naqueles pacientes, com risco de aspiração gástrica, em que não há suspeita de intubação traqueal difícil. A indicação correta da técnica, sua aplicação criteriosa e a utilização racional das drogas disponíveis podem promover condições excelentes de intubação, com curto período de latência, rápido retorno da consciência e da respiração espontânea, caso haja falha na intubação traqueal.

O presente artigo tem como objetivo discutir os métodos atualmente utilizados para controlar o volume e o pH do conteúdo gástrico, proteger as vias aéreas durante as manobras de intubação e reduzir o refluxo gastroesofágico.

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Artigo recomendado: The Value Proposition of Anesthesia Information Management Systems

Christoph B. Egger Halbeis, MD, DEAA,MBA^a,*,

Richard H. Epstein, MD, CPHIMS^b

^{Anesthesia Information Management Systems (AIMS) are information technology (IT) systems that are used as electronic anesthesia record keepers and allow the collection and analysis of anesthesia-related perioperative data. AIMS can be stand-alone systems or integrated modules of a clinical information system (CIS). AIMS are not yet widely established. It is estimated that these systems are currently deployed in less than 10% of all hospitals, although hard data supporting this figure are lacking. This low penetration rate is surprising for several reasons:}

IT systems for other ancillary hospital services (eg, radiology, pharmacy) are deployed almost universally.¹

Use of information systems technology has been widely touted as a means to improve patient care and safety.^2–4

AIMS have been available for more than 15 years.

A typical scenario for many anesthesiology departments or groups is that they would like to install AIMS, but the hospital declines to provide funds for the project. 

One explanation for this resistance is that the hospital believes such an expenditure of money and resources would create a situation that economists refer to as ‘‘nonintegrated positive externalities;’’ that is, the hospital pays for the AIMS but doesnot benefit from the investment. There are several ways a hospital might benefit from AIMS installations, however. In this article, we review tangible and intangible values of these systems and highlight the evidence basis for such assertions, where existent.

We have attempted to highlight those areas in which results from the published literature are ambiguous or the potential impact of the value added is limited in scope. We anticipate that this summary will provide a structure and methodology for anesthesiology departments and hospitals to assess the potential outcomes of an AIMS installation and support their managerial decision making for investing in this technology.

Areas of values from anesthesia information management systems referenced in the scientific literature

In general, IT projects are not optimal candidates for being evaluated with traditional valuation tools such as the return on investment (ROI) or the net present value approach.⁵ Because IT projects typically have a high degree of uncertainty (eg, technical difficulties, additional labor costs, time in which benefits start to be obtained is variable) and have indirect returns (eg, via changing the behavior of health care providers), alternative valuation tools such as the real option¹ pathway have been suggested. For example, the real option approach helps executives to clarify the role of uncertainty in the project evaluation and structure a CIS implementation project as a sequence of managerial decisions over time. Even if more complex valuation approaches were to be included in a hospital’s cost-benefit analysis of AIMS installation, it would be misleading to only include the monetary value in the decision making to invest in AIMS because many of the indirect or clinical benefits are hard to translate into cash flows. For example, if the availability of specific performance metrics captured by AIMS supports managerial decision, how should this be monetized?

O’Sullivan and colleagues⁶ recently examined the scientific evidence of how AIMS may reduce the cost of and the improve reimbursement for providing anesthesia services and found four evidence-based factors that contribute to a positive ROI:

• Reduction in anesthesia-related drug costs
• Improvement in staff scheduling and reducing staffing costs
• Increased anesthesia billing and capture of anesthesia-related charges
• Increased hospital reimbursement through improved hospital coding

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Artigo: Awareness during anesthesia

Beverley A. Orser MD PhD, C. David Mazer MD, Andrew J. Baker MD

Published at www.cmaj.ca on Dec. 11, 2007.

DOI:10.1503/cmaj.071761

More than 40 million patients receive anesthesia each year in North America. The risks associated with anesthesia have progressively decreased, but the mechanisms of action of anesthetic drugs remain poorly understood. This lack of knowledge has limited the optimum use of drugs that are currently available and has slowed efforts to develop even safer anesthetics. Many complex and lengthy surgical procedures, often performed on medically compromised patients, have been made possible by modern anesthetic techniques. However, anesthetic drugs, like other medications, have limitations, contraindications and adverse effects.

One of the more common concerns expressed by patients who are about to undergo anesthesia is that they will remember intraoperative events¹. For some, this concern will likely be heightened with the Nov. 30, 2007, release of the movie Awake, about a young patient who experiences intraoperative awareness during cardiac surgery (www.awakethemovie.com). Many anesthesiologists are already reporting an increase in the number of patients raising questions about intraoperative awareness, and surgeons and primary care physicians may also soon be faced with such enquiries. In this commentary, we define the nature of the problem of awareness, identify the risk factors, describe strategies to reduce the incidence of intraoperative awareness and point to resources for further information.

Intraoperative awareness is the unexpected and explicit recall by patients of events that occurred during anesthesia. As many as 1 or 2 in every 1000 patients who receive general anesthesia experience this outcome, and the incidence may be even higher among children^2-4. Most patients who remember intraoperative events do not experience pain; rather, they have vague auditory recall or a sense of dreaming and are not distressed by the experience⁵. However, some patients experience pain, which is occasionally severe. In a study involving 11 785 patients who had received general anesthesia, the incidence of awareness was 0.18% in cases in which neuromuscular blockers were used and 0.10% in the absence of such drugs³. Of the 19 patients who experienced recall, 7 (36%) reported some degree of pain, ranging from soreness in the throat because of the endotracheal tube to severe pain at the incision site³.

Patients may remember these events immediately after surgery, or hours or days later³. According to a study by Samuelsson and colleagues, most cases of awareness are inconsequential, but some patients experience prolonged and unwanted outcomes, including post-traumatic stress disorder or depression⁶. Late psychological symptoms, including nightmares, anxiety and flashbacks, occurred in 15 of 46 patients (33%) who experienced awareness. Reports of intraoperative awareness generally apply only to patients who have received general anesthesia, since painless auditory recall by patients receiving regional (e.g., epidural) anesthesia is not surprising. Patients who receive regional anesthesia often receive medication for sedation and anxiolysis but are usually arousable...

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Artigo recomendado: Adding ketamine to morphine for intravenous patient-controlled analgesia for acute postoperative pain: a qualitative review of randomized trials

M. Carstensen, and A. M. Møller

British Journal of Anaesthesia 104 (4): 401–6 (2010)

Abstract

In experimental trials, ketamine has been shown to reduce hyperalgesia, prevent opioid tolerance, and lower morphine consumption. Clinical trials have found contradictory results. We performed a review of randomized, double-blinded clinical trials of ketamine added to opioid in i.v. patient-controlled analgesia (PCA) for postoperative pain in order to clarify this controversy. Our primary aim was to compare the effectiveness and safety of postoperative administered ketamine in addition to opioid for i.v. PCA compared with i.v. PCA with opioid alone. Studies were identified from the Cochrane Library 2003, MEDLINE (1966–2009), and EMBASE (1980–2009) and by hand-searching reference lists from review articles and trials. Eleven studies were identified with a total of 887 patients. Quality and validity assessment was performed on all trials included using the Oxford Quality Scale with an average quality score of 4.5. Pain was assessed using visual analogue scales or verbal rating scales. Six studies showed significant improved postoperative analgesia with the addition of ketamine to opioids. Five studies showed no significant clinical improvement. For thoracic surgery, the addition of ketamine to opioid for i.v. PCA was superior to i.v. PCA opioid alone. The combination allows a significant reduction in pain score, cumulative morphine consumption, and postoperative desaturation. The benefit of adding ketamine to morphine in i.v. PCA for orthopaedic or abdominal surgery remains unclear. Owing to huge heterogeneity of studies and small sample sizes, larger double-blinded randomized studies showing greater degree of homogeneity are required to confirm these findings.

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29 de Julho: Seminário Internacional Sobre Uso Seguro de Medicamentos - Escola de Enfermagem da USP

O seminário acontece na sala 27 da EE. Às 8 horas serão checadas as inscrições e o evento se inicia às 8h30. A EE fica na Av. Doutor Enéas de Carvalho Aguiar, 419, próxima ao Metrô Clínicas, em São Paulo.

Mais informações: (11) 3061-7531 ou pelo site: http://www4.usp.br/index.php/saude/21716-ee-promove-seminario-internacional-sobre-uso-seguro-de-medicamentos

A Wake Up Safe Patient Safety Alert: Decreasing the Risks of Intravenous Medication Errors

Wake Up Safe, a component of The Society for Pediatric Anesthesia

UPDATE June 22, 2011

Wake up Safe has already issued a statement concerning medication errors (http://www.wakeupsafe.org/intravenousmederrors.iphtml), but we have now received many additional reports of problems with medications. We have received a total of 127 reports of serious adverse events occurring during anesthesia, and 23 of those reports are medication-related. With an approximate number of anesthetics of 250,000 in the institutions reporting to Wake up Safe, that suggests an incidence of serious medication errors of about 1 per 12,500 anesthetics. This finding confirms that medication-related events are an important problem in pediatric anesthesia, and the frequency of these events prompts us to issue another statement. It is likely that the total number of medication errors is much higher because Wake Up Safe institutions are only reporting errors that result in significant harm to the patient.

Of the 23 reports, 5 were wrong drug, 12 were wrong dose, 1 wrong route, 2 omissions of needed drugs, and 3 were possible adverse reactions.

Anesthesiologists are the only physicians who regularly give medications directly to patients. Furthermore, they are the only health care providers responsible for the entire medication delivery chain (order, prep, transport, administer, record, and monitor outcomes). Except when ordered medications are delivered in single unit doses from the pharmacy, the rapid paced nature of care in the operating room frequently precludes pre-administration double-checks commonly in place in other parts of the hospital.

Anesthesiologists have long known that safe management of medication is an important training topic, and pediatric anesthesiologists recognize the importance of training residents in safeguards that should be used when giving medications to children. Clearly from the reported events of medication errors, training alone is insufficient. Additional processes and tools should be explored to enhance medication safety in the OR.

The leadership of Wake up Safe feels that the Pediatric Anesthesia community should be aware of and vigilant for the problem of medication errors that occur during anesthesia in the OR. We invite practitioners and others to share solutions that they have developed to prevent medication errors in the OR.

Fonte: http://www.wakeupsafe.org/intravenousmederrors2.iphtml