[Risk management by reporting critical incidents. Vitamin K and ephedrine mix-up at a birthing unit]. / Risikostyring med rapportering af kritiske situationer. Forveksling af K-vitamin og ephedrin på en fødegang.

INTRODUCTION: Errors of medication are frequent causes of hazards to patients. It has been suggested that containers that look alike constitute a risk of such errors. In this article, we present an example of how reporting incidents of potential risks, can be applied in their clinical management. MATERIAL AND METHODS: As part of a medical technology assessment project on risk management in a delivery department, the staff were encouraged to report incidents that could create a potential risk to patients. The incidents were assessed by a project group as either a general problem to patient safety or a solitary incident. If considered a general problem, procedures should be changed and implemented in the department. RESULTS: Two incidents were reported, where ephedrine and adrenaline were found in a box supposed to contain vitamin K for new-born babies. These were considered a general problem by the project group, and the procedure for storing and managing ephedrine and adrenaline in the delivery department was changed to prevent new cases. DISCUSSION: Near misses occur more often than actual errors, and we argue that, as they are easier to discover, it is important to learn from them and thus prevent further incidents. A forum should be set up to exchange experiences of acknowledged risks, hazards, analytical results and preventive solutions.

[Incidence of adverse events in hospitals. A retrospective study of medical records]. / Forekomsten af utilsigtede haendelser på sygehuse. En retrospektiv gennemgang af journaler.

INTRODUCTION: Over the past decade a number of studies on the incidence and preventability of adverse events in the health care have been published in the US, Australia and the UK. So far no similar study has been performed in Denmark. In order to determine whether foreign findings could be generalised to Danish health care, a pilot study on adverse events was carried out in Danish acute care hospitals. METHOD: Chart reviews were carried out on 1.097 acute care hospital admissions, sampled from the central Danish National Patient Register. The sample was truly proportional with no over-sampling of high-risks groups. Chart reviews was done in 17 different acute care hospitals, reviewing between 20 and 204 admissions per hospital. Adverse events was identified using a three-step procedure: 1) Nurse screening by 18 criteria identifying high-risk groups. 2) Independent reviews by pairs of consultants. 3) In case of disagreement between second step consultants, two additional independent reviews was performed by new consultants (internist and surgeon) followed by conference. All chart reviews were performed independent of medical specialty. All nurses and doctors were senior and experienced clinicians. RESULTS: In 114 admissions 176 Adverse Events (AEs) were identified. The prevalence of admissions with adverse events were 9.0% of all admissions. Preventability of adverse events was found in 46 of admissions (40.4% of AEs). The adverse events caused on average a 7.0 days prolonged hospital stay. Most adverse events resulted in minor, transient disabilities. Permanent disability or death in relation to adverse event were recorded in 30 admissions. DISCUSSION: The findings from the Danish Adverse Event Study are similar to the results found in Australia, United Kingdom and the United States. It is therefore recommended that further Danish research, is directed towards high-risk groups focussing on narratives and intervention and towards research in primary health care.

Lack of postoperative pain relief after hysterectomy using preperitoneally administered bupivacaine.

BACKGROUND AND OBJECTIVES: It is well known that wound infiltration with local anesthetic can reduce postoperative pain in various degrees and with very few side effects. A previous study showed better analgesic effect when local anesthetic was applied in the subfascial, rather than the subcutaneous, layer. The present study investigated the effect of frequent bolus injections of bupivacaine (15 mL 2.5 mg/mL) preperitoneally through catheters placed intraoperatively in women who had undergone hysterectomy. METHODS: Postoperative pain and analgesic requirements were studied in a double-blind randomized trial including 41 patients. During surgery, the patients were randomized to one of two groups, and the investigators were blinded. Prior to closure of the peritoneum, the surgeon placed a catheter between the muscle layer and the peritoneum on each side of the wound. One group (n = 22) received bupivacaine (15 mL 2.5 mg/mL) every 4 hours for 48 hours via each catheter starting in the operating room. The placebo group (n = 19) received saline in a like manner. Postoperative pain was evaluated using a visual analog scale (VAS) and verbal rating scale (VRS) twice a day for 2 days at rest and on movement. Requirements of supplementary analgesics were monitored, as was wound infection after discharge. RESULTS: Bupivacaine administered preperitoneally did not improve analgesia at rest, during coughing, or during mobilization compared with saline. No difference between the groups was found regarding analgesic requirements. No complications of postoperative wound healing or toxic side effects were seen. CONCLUSION: Bolus injections of bupivacaine through intraoperative placed catheters did not improve analgesia postoperatively compared with saline injections.

[Ambulatory laparoscopic cholecystectomy. Feasibility and convalescence]. / Ambulant laparoskopisk kolecystektomi. Gennemførlighed og rekonvalescens.

UNLABELLED: The purpose was to describe feasibility of and convalescence after laparoscopic cholecystectomy in a day case set up in this prospective, open, and descriptive study. Fifty consecutive patients referred for elective cholecystectomy participated. An overnight stay was planned for 13 patients, (12 because they lived alone, one because of pulmonary disease ASA III). The operation was in all cases performed under combined epidural-general anaesthesia. The primary issues were duration of hospital stay, reasons for delayed discharge, frequencies of nausea and vomiting, as well as duration of convalescence and reasons for postponement of return to work or recreational activities. Twenty-six patients (of 37 candidates for day case surgery) were discharged on the day of surgery and 16 on the first postoperative day. Eleven patients had nausea, and three vomited during the first three postoperative hours. Pain was the most common contributory reason for overnight stay (17 patients, eight of these being planned day-case patients who stayed overnight). The patients were recommended to resume work and recreational activities after 48 hours, but 35 patients did not observe this recommendation. The median number of days off work or recreational activity was four days (2-8), including the day of surgery. Pain was the most common contributory reason (19 patients). CONCLUSIONS: Laparoscopic cholecystectomy can be performed as an outpatient operation in more than half of all patients, in approximately 70% of patients not living alone, and with only 15% of the patients requiring more than one over-night stay. Postoperative pain is the primary reason for both delayed discharge and prolonged convalescence. Up to one week's duration of convalescence is recommended.

[Reduced sense of taste as a complication of the laryngeal mask use]. / Nedsat smagssans som komplikation til anvendelse af larynxmaske.

We report a unilateral lingual nerve paralysis following the use of a laryngeal mask airway in a 73-year-old man with hypertrophy of the prostate undergoing a TUR-P. The operation was performed in general anaesthesia using propofol, fentanyl, alfentanil and ventilation with 100% oxygen. The operation was uncomplicated and had a duration of two hours and twenty minutes. A week later the patient perceived a reduced sense of taste. Six months later the situation was unaltered.

[Laparoscopic excision of the rectum. An advanced technique or true clinical progress?]. / Laparoskopisk rectumeksstirpation. En avanceret teknisk øvelse eller et reelt klinisk fremskridt?

A very high postoperative morbidity is seen after conventional open abdominoperineal excision of the rectum. The use of laparoscopic technique for this operation implies theoretical benefits, but only sparse clinical data have been published and advantages have not yet been convincingly documented. In the light of our experiences with laparoscopic colonic resections in high-risk patients and in two patients with abdominoperineal excision we propose the following perioperative regime for elderly patients undergoing rectal excision: Laparoscopic operation followed by continuous epidural analgesia, opioid-free pain treatment, restricted administration of fluids perioperatively, early enteral nutrition and enforced mobilisation as well as intensified training in colostomy care-that should already be started preoperatively. Preliminary results suggest that morbidity and the need for hospital stay can be considerably reduced by such an approach. A prospective evaluation of this strategy on the immediate postoperative results will be followed by long-term results concerning survival, local recurrence rates, distant metastases and the risk of port-site metastases.

[Preoperative or postoperative local anesthesia. Effect on postoperative pain treatment]. / Prae- eller postoperativt lokalanalgetikum. Effekt på postoperativ smertebehandling.

A randomized, double-blind trial was conducted to compare the efficacy of preincisional and postincisional wound infiltration with 1% lidocaine (40 ml) on postoperative pain. Thirty-seven patients scheduled for elective inguinal herniotomy participated. The demand for additional postoperative analgesics occurred earlier in those who received lidocaine infiltration after incision (165 min) than in those who received preincisional lidocaine (225 min), p < 0.05). The preincisional lidocaine infiltration group also had fewer patients requiring supplemental analgesics (58%) than the postincisional group (94%) (p < 0.05). We conclude that preincisional infiltration of the surgical wound with lidocaine is a more effective method for postoperative analgesia than postincisional infiltration.

[Treatment of postoperative pain]. / Postoperativ smertebehandling.

Intensive research during recent years concerning treatment of postoperative pain has demonstrated that the majority of operation patients can be rendered free from pain but that this is far from being the case in clinical practice. This article reviews the physiological mechanisms of acute pain and the methods available for treatment of pain related to acute physiology of pain. Postoperative treatment of pain should be aggressive with the object of preventing pain and normalizing the vital functions with the object of reducing the perioperative morbidity and mortality. A series of recommendations are given for treatment of pain after surgical intervention.