How a single perioperative delirium case can make the difference.

This report describes how postoperative delirium in an elderly man during COVID-19 pandemic led to a serious event involving a central venous catheter. Delirium is a common cause of perioperative morbidity and mortality, and is characterised by an alteration in consciousness and perception and a reduced ability to focus, sustain or shift attention. The event was analysed by a multidisciplinary committee which developed a risk stratification delirium protocol in order to prevent similar events in the future.

Programación de cirugía electiva segura en tiempos de COVID-19. La importancia del trabajo colaborativo / Safe elective surgery during COVID-19. The relevance of collaborative work

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Errores de medicación: un reto para la anestesiología / Medication errors: a challenge for anesthesiology

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Recomendaciones de seguridad del paciente para sedaciones en procedimientos fuera del área quirúrgica / Patient safety recommendations for out of operating room procedure sedation

Introducción. La demanda de administración de sedación para procedimientos en entornos alejados de quirófano ha crecido extraordinariamente y cada vez requiere un abordaje más complejo. Por diferentes motivos, hoy en día la atención para estas sedaciones está sujeta a mucha variabilidad. Creemos que es necesaria una aproximación a ella desde la seguridad del paciente más que desde intereses corporativos o economicistas. Método. Dentro del Sistema de Notificación en Seguridad en Anestesia y Reanimación (SENSAR) se constituyó un grupo de trabajo de expertos para la redacción de una serie de recomendaciones a través de una revisión no sistemática. El resultado de dicho esfuerzo fue validado mediante 2 rondas de encuestas siguiendo una adaptación del método Delphi ante un panel de expertos de 31 anestesiólogos. Resultados. Las recomendaciones resultantes incluyen la valoración previa, los requisitos materiales y de personal para la sedación del procedimiento, las recomendaciones para después del procedimiento, registros de actividad y controles de actividad y calidad. Tras las 2 rondas Delphi, fueron aprobadas por más del 70% de los miembros del panel de expertos. Conclusión. Presentamos unas recomendaciones para la administración segura de sedación en procedimientos fuera de quirófano centradas en el paciente y elaboradas con el criterio de los profesionales con mayor conocimiento en la administración de la misma y que puede servir como base para la reducción de la variabilidad y mejora de la seguridad del paciente en la organización de la atención sanitaria en este ámbito (AU)

Introduction. There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. Method. We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. Results. The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. Conclusion. We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare (AU)

[Patient safety recommendations for out of operating room procedure sedation]. / Recomendaciones de seguridad del paciente para sedaciones en procedimientos fuera del área quirúrgica.

INTRODUCTION: There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. METHOD: We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. RESULTS: The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. CONCLUSION: We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare.

Recomendaciones de seguridad del paciente para sedaciones en procedimientos fuera del área quirúrgica / Patient safety recommendations for out of operating room procedure sedation

Introducción. La demanda de administración de sedación para procedimientos en entornos alejados de quirófano ha crecido extraordinariamente y cada vez requiere un abordaje más complejo. Por diferentes motivos, hoy en día la atención para estas sedaciones está sujeta a mucha variabilidad. Creemos que es necesaria una aproximación a ella desde la seguridad del paciente más que desde intereses corporativos o economicistas. Método. Dentro del Sistema de Notificación en Seguridad en Anestesia y Reanimación (SENSAR) se constituyó un grupo de trabajo de expertos para la redacción de una serie de recomendaciones a través de una revisión no sistemática. El resultado de dicho esfuerzo fue validado mediante 2 rondas de encuestas siguiendo una adaptación del método Delphi ante un panel de expertos de 31 anestesiólogos. Resultados. Las recomendaciones resultantes incluyen la valoración previa, los requisitos materiales y de personal para la sedación del procedimiento, las recomendaciones para después del procedimiento, registros de actividad y controles de actividad y calidad. Tras las 2 rondas Delphi, fueron aprobadas por más del 70% de los miembros del panel de expertos. Conclusión. Presentamos unas recomendaciones para la administración segura de sedación en procedimientos fuera de quirófano centradas en el paciente y elaboradas con el criterio de los profesionales con mayor conocimiento en la administración de la misma y que puede servir como base para la reducción de la variabilidad y mejora de la seguridad del paciente en la organización de la atención sanitaria en este ámbito (AU)

Introduction. There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. Method. We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. Results. The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. Conclusion. We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare (AU)

Patient safety recommendations for out of operating room procedure sedation. / Recomendaciones de seguridad del paciente para sedaciones en procedimientos fuera del área quirúrgica.

INTRODUCTION: There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. METHOD: We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. RESULTS: The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. CONCLUSION: We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare.

[Application of a critical incident reporting and analysis system in an anesthesiology department]. / Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia.

OBJECTIVES: To ascertain the changes in anesthesia-related morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; chi2 test, P < 0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; chi2, P < 0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors.

Sistemas de comunicación de incidentes y seguridad del paciente en anestesia / Incident reporting systems and patient safety in anesthesia

Los sistemas de comunicación de incidentes recogeninformación sobre sucesos adversos, errores, complicacioneso problemas con el objetivo de analizar sus causasy sugerir cambios para evitar su repetición. Actualmenteson parte de los programas de seguridad clínica en diversospaíses. Aunque existe controversia acerca de cuálesserían las características del sistema de comunicaciónideal, para que éste tenga éxito se necesita una cultura deseguridad asentada en la organización. El planteamientode base asume que aunque los errores son inherentes alproceso humano casi siempre los propicia una cadena defallos en el sistema, por lo que los sistemas de comunicaciónse diseñan para estimular una cultura de aprendizajey no de culpabilización. Sus principales limitacionesson la posibilidad de infracomunicación, las diferentesterminologías y conceptos utilizados, la falta de recursospara su investigación y desarrollo, y la escasa o nulalegislación que permita su buen uso sin implicacioneslegales

Incident reporting schemes collect information onadverse events, errors, complications, or problems withthe aim of analyzing their causes and suggesting changesto prevent recurrence. Such schemes are currently partof clinical safety programs in various countries. Althoughthe ideal form for a reporting system is debated,an essential part of its success will be the establishmentof a culture of safety within an organization. The underlyingassumption is that even though errors are aninherent part of a process that relies on human beings, theyare nearly always favored by a chain of system failures.Therefore, reporting is intended to stimulate a culture oflearning rather than assigning blame. The main limitationsof such schemes are under reporting, the use of differentterms and concepts, the lack of resources for researchand development, and the scarcity or lack oflegislation to guarantee the proper use of informationwithout legal consequences

Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia / Application of a critical incident reporting and analysis system in an anesthesiology department

OBJETIVOS: Conocer los cambios en la morbi-mortalidad anestésica con la utilización de un sistema de comunicación de incidentes críticos y valorar los efectos de la resolución de los factores de error detectados. PACIENTES Y MÉTODOS: Consideramos incidente crítico toda situación en la que se redujo o pudo haberse reducido el margen de seguridad del paciente. Analizamos el periodo entre enero de 1999 y diciembre de 2004. RESULTADOS: Se realizaron 68.627 procedimientos anestésicos y se comunicaron 547 incidentes críticos (0,79%). En 279 incidentes (51%) se identificó un error activo. Los factores latentes asociados con mayor frecuencia fueron el error de diagnóstico de la situación, los problemas de comunicación y la falta de comprobación del equipamiento y de los fármacos. El 81,8% de los incidentes no tuvieron ningún efecto sobre el paciente. En el 78,9% el incidente se consideró evitable. La introducción de una lista de comprobación del equipamiento antes de la anestesia redujo los incidentes de 90 por 21809 casos en 31 meses a 34 por 22.064 casos en 29 meses; χ, p<0,05; odds ratio [OR]= 2,68; intervalo de confianza [IC] del 95%= 1,80-3,9811. El etiquetado de jeringas redujo los errores en la administración de medicación de 45 por 21.809 casos en 31 meses a 27 por 22.064 casos en 29 meses; χ, p<0,05; OR= 1,68; IC del 95%= 1,04-2,72. CONCLUSIONES: Como consecuencia del análisis sistemático de los incidentes se adoptaron distintas medidas correctoras, algunas de las cuales demostraron una reducción estadísticamente significativa en los incidentes de equipamiento y los incidentes farmacológicos

OBJECTIVES: To ascertain the changes in anesthesiarelated morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; χ2 test, P<0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; χ2, P<0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors

Cardiac output by femoral arterial thermodilution-calibrated pulse contour analysis during liver transplantation: comparison with pulmonary artery thermodilution.

PURPOSE: The continuous monitoring of the cardiac output during liver transplantation (LT) is an essential part of the intraoperative management of the patient's hemodynamics. To verify the accuracy of a new method based on femoral artery thermodilution-calibrated pulse contour analysis (PCCO) during LT, we compared the technique with the results of an intermittent pulmonary artery thermodilution method (ICO). METHOD: A prospective study included 314 paired cardiac output measurements at 10 sampling times in 35 patients undergoing LT. After initial calibration of the pulse contour analysis, no further recalibrations were performed. Bland and Altman's statistical method, one-way ANOVA, and one sample t tests were used for the analysis of the data. A P<.05 was considered significant. RESULTS: There was a small bias 0.18 L x min(-1) (6.29% from the ICO) for the whole sample of paired measurements, associated with 95% limits of agreement of +/-4.72 (68.89%) L x min(-1). The additional analysis showed comparable biases and limits of agreement for any single time in the study period. The difference PCCO-ICO showed a negative sign for ICO >10 L x min(-1) (P<.001) and a positive sign for ICO <5 L x min(-1) (P<.001). It was greater during infusion of a vasoactive drug (P<.001). CONCLUSION: The pulse contour analysis was found to be an unsatisfactory substitute for intermittent thermodilution measurement of cardiac output during the LT.