Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback.

BACKGROUND: The potential severity of wrong patient/procedure/site of surgery and the view that these events are avoidable, make the prevention of such errors a priority. An intervention was set up to develop a verification protocol for checking patient identity and the site of surgery with periodic audits to measure compliance while providing feedback. ASSESSMENT OF PROBLEM: A nurse auditor performed the compliance audits in inpatients and outpatients during three consecutive 3-month periods and three 1-month follow-up periods; 11 audit criteria were recorded, as well as reasons for not performing a check. STRATEGY FOR CHANGE: The nurse auditor provided feedback to the health professionals, including discussion of inadequate checks. RESULTS: 1,000 interactions between patients and their anaesthetist or nurse anaesthetist were observed. Between the first and second audit periods compliance with all audit criteria except "surgical site marked" noticeably improved, such as the proportion of patients whose identities were checked (62.6% to 81.4%); full compliance with protocol in patient identity checks (9.7% to 38.1%); proportion of site of surgery checks carried out (77.1% to 92.6%); and full compliance with protocol in site of surgery checks (32.2% to 52.0%). Thereafter, compliance was stable for most criteria. The reason for failure to perform checks of patient identity or site of surgery was mostly that the anaesthetist in charge had seen the patient at the preanaesthetic consultation. LESSONS AND MESSAGES: By combining the implementation of a verification protocol with periodic audits with feedback, the intervention changed practice and increased compliance with patient identity and site of surgery checks. The impact of the intervention was limited by communication problems between patients and professionals, and lack of collaboration with surgical services.

Drug selection errors in relation to medication labels: a simulation study.

The aim of this study was to assess the impact of differences in drug label information on injectable drug selection errors. Differences in the display of drug strength information were assessed in a randomised controlled trial involving ward nurses, intensive care nurses, nurse anaesthetists, ward physicians, and anaesthetists. A set of 24 on-screen tasks were constructed. For each task, a label corresponding to an instruction consisting of two from three possible pieces of information (concentration, quantity, volume) had to be selected from a list of 10 items. The set was presented three times to participants using three different label formats. Format A provided two pieces of strength information different from those in the instruction. Format B and C provided all three pieces in a random and a fixed sequence, respectively. The frequency of errors was statistically higher with formats A and B than with format C, and greater in nurses than in anaesthetists. Regulatory bodies should therefore implement a standard requiring that the concentration (expressed in 'mg x ml(-1)'), the amount and the volume of drug be displayed on medication labels in fixed locations.

Measuring human-error probabilities in drug preparation: a pilot simulation study.

OBJECTIVES: Designing a safe medication process requires the ability to model its reliability using methods such as probabilistic risk assessment (PRA). However, lack of data, especially on human-error probabilities (HEPs), limits its use. To assess whether small-scale simulations could help generate HEP data, a pilot study was conducted among nurses and anaesthetists. It focused on two core activities, namely, the manual preparation of medications and the arithmetic necessary to prepare drugs. Its specific objectives were to evaluate whether HEPs could be high enough to be measurable and to determine whether these HEPs could be sensitive to individuals and task details. These would give some insight into the level of detail required by PRA analysis. METHODS: Thirty nurse and 28 anaesthetist volunteers were involved in the experiment. Nurses and anaesthetists had to prepare medications for 20 patients and 22 syringes of various drugs, respectively. Both groups had to perform 22 calculations relating to the preparation of drugs. HEPs, distribution of HEPs and dependency of HEPs on individuals and task details were assessed. RESULTS: In the preparation tasks, overall HEP was 3.0% for nurses and 6.5% for anaesthetists. In the arithmetic tasks, overall HEP was 23.8% for nurses and 8.9% for anaesthetists. A statistically significant difference was noted between the two groups. In both preparation and arithmetic tasks, HEPs were dependent on individual nurses but not on individual anaesthetists. In every instance, HEPs were dependent on task details. CONCLUSION: Our study illustrates that small-scale simulations represent an interesting way of generating HEPs. HEPs are, indeed, in the range of 10(-2) and 10(-1). But in most cases, HEPs depend heavily on operators and task details. This dependency means that the influence of these parameters must be determined before advanced PRA analysis. There is therefore an urgent need to develop experimental research into assessing this influence by means of randomised controlled trials.

Using system analysis to build a safety culture: improving the reliability of epidural analgesia.

BACKGROUND: A potentially dangerous situation was revealed by an incident report describing the use of an inappropriate device to administer post-operative epidural analgesia to a patient on a surgical ward. The incident occurred in a 1200-bed university affiliated tertiary hospital (Geneva University Hospitals, HUG) and involved three clinical departments: anaesthesiology, the surgical intensive care unit and urology. METHODS: A multidisciplinary system analysis was carried out to identify care-delivery problems and contributory factors. Corrective actions were devised on the basis of their ability to prevent and absorb unsafe situations. RESULTS: The system analysis identified three care-delivery problems in relation to the management of epidural analgesia. It enabled medical and nursing managers to adopt an interdepartmental set of corrective actions: a common protocol for post-operative epidural analgesia, leading to the exclusive use of patient-controlled epidural analgesia (PCEA) pumps; greater availability of the patient-controlled pumps; the dissemination of guidelines; permanent proactive training of nurses by the acute-pain team; the clarification of medical responsibilities; and a common help-line phone number for all surgical departments. DISCUSSION: The analysis provided a convincing exposure of various care-delivery problems and their corresponding contributory factors, as well as an opportunity to address a systemic issue in a multidisciplinary way. By thus facilitating decisions and corrective actions, the analysis was instrumental in strengthening our safety culture.

[Perception and communication of medical risk which implications for preoperative anaesthetic consultations?]. / La perception et la communication du risque médical. Quelles implications pour les consultations préanesthésiques?

Informing patients about available treatments, their advantages and disadvantages, as well as the associated risks, is critical to obtain an informed consent and is the responsibility of physicians, including anaesthesiologists. However, risks issues are not systematically discussed during anaesthesia consultations or are addressed in a vague and incomplete way. In order to improve communication and the quality of the informed consent, it is therefore essential to scrutinize problems linked to communication about risks. This article is based on a review of French and English literature on perception and communication about medical risks. Its objectives are for the one hand to summarize the main difficulties concerning risk communication in medicine and, on the other hand, to offer tools that can foster quality communication with patients especially during anaesthesia consultations.

Acceptability of identification bracelets for hospital inpatients.

OBJECTIVE: To evaluate whether hospitalised patients would agree to wear an identification bracelet and whether patient acceptability is improved by more detailed explanations or by using a code instead of a name on the bracelet. DESIGN: Patient survey that tested two variables in a randomised factorial design. Explanations about identification bracelets were given (a) with or without examples of situations where patient identification may be important, and (b) with the patient name or an anonymous code appearing on the bracelet. SETTING: Swiss teaching hospital where wearing of identification bracelets was not systematic. PARTICIPANTS: Adult patients discharged from hospital (n = 1411). MAIN OUTCOME MEASURES: Patients' responses to the questions: (a) should the hospital introduce a compulsory identification bracelet? and (b) would the patient agree to wear such a bracelet? RESULTS: Globally, 83.9% of patients thought that the hospital should introduce bracelets and 90.2% stated that they would agree to wear one. Providing examples increased support for both the hospital policy (87.9% v 79.2%, p<0.001) and personal acceptance (92.2% v 88.1%, p = 0.015). Whether or not the bracelet carried the patient's name or an anonymous code did not influence patient choice. CONCLUSIONS: The majority of patients were in favour of wearing an identification bracelet during their hospital stay. This proportion increased significantly when an explanation based on examples of the consequences of incorrect patient identification had been provided.

Root-cause analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit.

BACKGROUND: To show how root-cause analysis can identify system-level factors causing critical incidents and accidents, we present an investigation of the occlusion of an airway filter during anaesthesia. METHOD: The investigation was based on a framework specifically developed for the analysis of medical accidents. This framework helped to identify the chronology and outcome of the case, the care management problems and the factors that led to the event. Information was obtained by interviewing the anaesthesiologist in charge of the patient. RESULTS: Occlusion was not recognized because the filter was hidden under the drapes and below the patient's head. To reduce the frequency of this event, we recommend that filters should be visible, placed above the level of the patient's body, or mounted on the expiratory circuit, at a distance from patient's airway. CONCLUSIONS: To allow appropriate corrective actions, critical incidents and accidents should be systematically investigated using root-cause analysis.

Quality improvement report: Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas analysis in intensive care.

PROBLEM: Need to decrease the number of requests for arterial blood gas analysis and increase their appropriateness to reduce the amount of blood drawn from patients, the time wasted by nurses, and the related cost. DESIGN: Assessment of the impact of a multifaceted intervention aimed at changing requests for arterial blood gas analysis in a before and after study. BACKGROUND AND SETTING: Twenty bed surgical intensive care unit of a tertiary university affiliated hospital, receiving 1500 patients per year. KEY MEASURES FOR IMPROVEMENT: Number of tests per patient day, proportion of tests complying with current guideline, and safety indicators (mortality, incident rate, length of stay). Comparison of three 10 month periods corresponding to baseline, pilot (first version of the guideline), and consolidated (second version of the guideline) periods from March 1997 to August 1999. STRATEGIES FOR CHANGE: Multifaceted intervention combining a new guideline developed by a multidisciplinary group, educational sessions, and monthly feedback about adherence to the guideline and use of blood gas analysis. EFFECTS OF CHANGE: Substantial decrease in the number of tests per patient day (from 8.2 to 4.8; P<0.0001), associated with increased adherence to the guideline (from 53% to 80%, P<0.0001). No significant variation of safety indicators. LESSONS LEARNT: A multifaceted intervention can substantially decrease the number of requests for arterial blood gas analysis and increase their appropriateness without affecting patient safety.

Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?

BACKGROUND: Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. OBJECTIVES: To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. METHODS: As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. RESULTS: During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction). CONCLUSION: Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting.

Outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery: a retrospective review of perioperative setting and outcome.

STUDY OBJECTIVE: To report the rapid shift from inpatient to outpatient surgery that occurred after opening an outpatient preoperative evaluation clinic and the perioperative complications and mortality rates before and after this intervention. DESIGN: Monthly variations of total volume of procedures and percentages of outpatient procedures were analyzed retrospectively using control charts over two consecutive 10-month periods before and after the intervention. For each type of procedure (inpatient vs. outpatient), the perioperative complications and 30-day mortality rates were compared between periods. SETTING: The Veterans Affairs Palo Alto Health Care System, Palo Alto, California. PATIENTS: Patients who underwent 3,159 inpatient or outpatient procedures in the main operating room suite during the control period were compared with patients who underwent 3,190 procedures in the same operating room suite during the intervention period. INTERVENTION: The establishment of an outpatient preoperative evaluation clinic. MEASUREMENTS AND MAIN RESULTS: For each period, the total monthly surgical volume (inpatient and outpatient), perioperative complications, deaths within 30 days of surgery, and the number of procedures performed on patients classified as ASA physical status III, IV, or V were analyzed. The monthly total number of procedures was stable over both periods, but the monthly percentage of outpatient procedures departed from its baseline immediately after establishing the clinic (control period: 24.7%; study period: 45.4%; p << 0.0001). Finally, the perioperative complication rate did not change for outpatient procedures but increased for inpatient procedures (control period: 2.31%; study period: 3.50%; p < 0.05). The 30-day mortality rate remained unchanged for inpatient and outpatient procedures. CONCLUSIONS: Establishing an outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery at a government funded hospital without a concomitant increase in perioperative morbidity or mortality.

SHARE: a tool to analyze and assess strategies in health care organization management.

In health care organizations, management of both human and material resources implies decision making. When seemingly equivalent strategies are possible, simulation can help to make a decision on better grounds. The SHARE workframe was designed to address the specificities of health care and to provide a comprehensive environment for modelling and simulating health care processes. The typology of objects is defined as Actors, subdivided in Clients and Resources and Elementary Operations. Graphical tools allow us to build processes from these objects and to create their relationships. Various strategies based on either clinical or managerial changes may be investigated. After a simulation, graphical tools allow us to display summary information on the utilization of all actors, waiting times, and goodness of execution. The use of SHARE is exemplified with the analysis and simulation of changes in the Pulmonary Function Testing Laboratory of the Saint-Antoine Hospital, Paris.

Modelling health care processes with SHARE.

This paper describes the "SHARE" workframe, designed to provide a comprehensive environment for modeling and simulating health care processes. The objects defined within SHARE are Actors, subdivided in Clients and Resources, and Elementary Operations. Graphical tools allow to build processes from these objects, and to specify their relationships. Various strategies based on either clinical or managerial changes may be investigated. Summary information on the utilization of all actors, on waiting times and goodness of execution may be displayed after a simulation. Better description of processes, and their study a priori will improve reliability, quality of care and satisfaction of patients.

Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery.

UNLABELLED: Interventions that decrease perioperative length of stay can result in considerable cost-savings. This study assesses the impact of same-day admission using outpatient preoperative evaluation on the lengths of stay and hospital costs for patients who underwent carotid end-arterectomy (CEA) or lower extremity revascularization (LER). Patient characteristics and length of stay were compared for two 1-yr periods before and after outpatient preoperative evaluation had been implemented. There were no significant differences before and after the initiation of outpatient preoperative evaluation in the CEA and LER groups in mean age and ASA physical status distributions. The average preoperative length of stay decreased significantly from 7.0 to 1.9 days in the CEA group and from 9.0 to 2.8 days in the LER group. This reduction in the length of stay was associated with a cost-savings of $900 per patient and did not have an adverse effect on patient outcome. We conclude that outpatient preoperative evaluation clinics reduce the cost and length of stay in vascular surgery patients. IMPLICATIONS: We found that outpatient preoperative evaluation and same-day admission were associated with a decrease of 4.5 days in the preoperative length of stay for carotid endarterectomy and lower-extremity revascularization. This was not accompanied by increased mortality and led to hospital cost-savings of approximately $900 per patient.

AUDILAB: a knowledge-based quality audit simulator for testing laboratories.

In order to obtain an accreditation, a laboratory must be prepared to provide a point-by-point check of various activities against the chosen reference standard, both from a general point of view and in relation to details of application. This paper describes AUDILAB, a computerized simulator accessible by network, able to provide testing laboratories with realistic quality audits performed in a customized way. AUDILAB establishes a detailed list of strengths (compliance with corresponding requirements of established standards) and weaknesses (improvements needed for laboratory's accreditation). The standard used by AUDILAB is the EN 45001 "General criteria for the operation of testing laboratories". A preliminary validation has already been completed. AUDILAB became operational in September 1993.

A sequential procedure to test the progressive decrease of rare adverse events.

A program to construct the Rapid Sequential Test (R-ST), a sequential procedure to test the decrease of the rate of rare adverse events, is described. This sequential procedure is constructed with the Sequential Probability Ratio method. It relies on a model for the progressive decrease in the rate of adverse events from a given initial rate to a target rate, during a transition period. The program allows one to calculate the bounds of rejection of the R-ST, and to study its power under various types of decrease. It is shown that the R-ST gives a conclusion faster than standard sequential procedures for the same type I and II error, saving at least one quarter of the trials completed during the transition period. The use of the software to construct R-STs is discussed with respect to the specification of the model.

Status of electronic reporting of notifiable conditions in the United States and Europe.

OBJECTIVE: To improve the computer connectivity and network strategies to connect U.S. county health departments (CHDs), state health departments (SHDs), and the Centers for Disease Control (CDC) for reporting notifiable conditions. METHODS: HSPNET-L mailing list discussions and individual Internet communications were used to compare selected features of notifiable conditions networking in the United States, France, and the United Kingdom. RESULTS: In the US, the CHD is the agency that first responds to an infectious disease outbreak on receiving notifications from physicians. Prompt recognition by the SHD that a widespread outbreak has occurred depends on the way in which county data are received, the "age" of the data, and the time taken to analyze them. Similarly, the recognition of the national scale of the outbreak depends on the promptness with which SHDs report to the CDC and the age of the data. An analysis of the French Communicable Disease Network suggests that an expansion of electronic links between US CHDs and SHDs will improve timeliness. Electronic data exchange allows CHDs to set up a local database and reduces transcription errors, mailing costs, and telephone costs. CONCLUSION: A fuller use of e-mail or other electronic communication by US CHDs will allow them to use a local database as a tool for managing local disease outbreaks more effectively and independently. Federal and state agency access to the CHD databases will enable early reporting of epidemic outbreaks. Periodic posting of public health information on Internet servers is recommended for immediate access to the public health data by Internet users worldwide.

[Quality assurance and prevention of immuno-hemolytic incidents in blood transfusion]. / Assurance de la qualité et prévention des incidents immuno-hémolytiques en transfusion sanguine.

Direct and indirect measures of the reliability of the transfusion process are described. These measures can be used to assess the improvement of the transfusion process with a view to preventing hemolytic incidents. Quality assurance arrangements required by their use are made clear. The stress is put upon four points: processes must be formalized and standardised; quality audits must become a routine part of the transfusion process; the system of error reporting must be extended to include all failures; anonymity must be insured to improve reporting.