Drug errors: consequences, mechanisms, and avoidance.

Medication errors are common throughout healthcare and result in significant human and financial cost. Prospective studies suggest that the error rate in anaesthesia is around one error in every 133 anaesthetics. There are several categories of medication error ranging from slips and lapses to fixation errors and deliberate violations. Violations may be more likely in organizations with a tendency to blame front-line workers, a tendency to deny the existence of latent conditions, and a blinkered pursuit of productivity indicators. In these organizations, borderline-tolerated conditions of use may occur which blur the distinction between safe and unsafe practice. Latent conditions will also make the error at the 'sharp end' more likely to result in actual patient harm. Several complementary strategies are proposed which may result in fewer medication errors. At the organizational level, developing a safety culture and promoting robust error reporting systems is key. The individual anaesthetist can play a part in this, setting an example to other members of the team in vigilance for errors, creating a safety climate with psychological safety, and reporting and learning from errors.

Low- to high-fidelity simulation - a continuum of medical education?

CONTEXT: Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models. AIM: This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.

Integrating human factors into the medical curriculum.

BACKGROUND: The study of human factors is a scientific discipline that deals with the interactions between human beings and the elements of a system. This is important because shortcomings in these areas, if unchecked, can result in adverse outcomes. Research into human factors in industries where safety is paramount has provided the basis of countermeasures against human error. Adverse outcomes in medicine resulting from human error exact a high cost in both patient suffering and financial outlay. CRM TRAINING: One of the approaches used to minimise the effect of human error is to train people in a set of knowledge, skills and attitudes that underpin the domain-specific competencies for that profession. These are referred to as non-technical skills (NTS). In aviation, such an approach has been shown to be both translatable from the training environment to the workplace and effective in reducing adverse outcomes. DISCUSSION: Medicine has incorporated this style of training, usually centred around simulator-based courses, but as yet in a piecemeal, episodic fashion which relies on participants volunteering to attend courses. Unlike other industries there is no systematic approach to linking the content of this teaching with the more conventional range of topics. As a consequence it is difficult to assess the impact of human factors training in medicine. This is partly because very little work has been done to date in identifying the key non-technical skills required in medicine, and the overall experience of workplace based assessment is limited. Lessons from other high reliability organisations may help to address the main challenges of developing the content, integrating it into the curriculum, reinforcing the concepts in the workplace through staff development and establishing its role in summative assessment.

Comparison of midazolam with propofol for sedation in outpatient bronchoscopy.

We have compared sedation for fibreoptic bronchoscopy provided by incremental doses of midazolam with that provided by a computer-controlled infusion of propofol. These two methods were compared in terms of operator and patient acceptability, anxiolysis, effects on systolic arterial pressure and oxygen saturation. Tests were made also of memory and motor reactions, before and 60 min after the end of the procedure. Acceptability to operators and patients was high in both groups. There were no significant differences between the groups in systemic arterial pressure or anxiolysis. Oxygen saturation decreased in both groups (propofol group median 83% (range 69-95%); midazolam group median 86% (range 77-95%)) (ns). The median recovery time was 5 min (range 5-10 min) in the propofol group and 10 min (range 5-40 min) in the midazolam group (P < 0.01). Memory and motor reaction times 60 min after the end of the procedure did not differ from baseline in the propofol group, but were significantly impaired in the midazolam group.

Assessing collateral circulation in the hand--four methods compared.

Four ways to assess the collateral circulation in the hand were compared. No correlation was shown between the Doppler ultrasound method and those that used either the pulse monitor or the Ohmeda Biox 3700 pulse oximeter. The study was unable to confirm suggested benefits of these methods in assessing adequacy of collateral flow in the hands of unconscious patients.

Atracurium--a post-marketing surveillance study: U.K. study and discussion.

Two companion post-marketing studies have evaluated the frequency of adverse events amongst patients receiving atracurium. In this second report, we describe the Scottish study and discuss findings in both centres. In this study we compare the frequency of adverse events in 477 patients receiving atracurium with those in 484 patients who received vecuronium. The frequency of reported serious adverse events was low during surgery and in the recovery room. Although the overall incidence of adverse experiences was slightly lower after atracurium, there were no significant difference between the groups in frequency of major adverse events. This type of study is believed to be of value in the future surveillance of new drugs for hospital use.

Ibuprofen in the management of postoperative pain.

The effect of the regular administration of ibuprofen on pain following abdominal surgery was investigated in a double-blind placebo-controlled study. The analgesic action of ibuprofen was measured by a reduction in the amount of morphine self-administered from an On-Demand Analgesic Computer. Pain scores, nausea scores and blood loss were similar in both groups, but patients receiving ibuprofen demanded significantly less morphine in the 24 h after surgery.

Patient-controlled analgesia. Experience of two new machines.

Two modern patient-controlled analgesia pumps have been evaluated in the laboratory and in clinical use. Both machines generally performed satisfactorily and patients achieved good pain relief from self-administered morphine. The relative merits of the two pumps are discussed and although the on demand analgesic computer is preferred, a substantial investment of time on the ward is required to provide continuous patient-controlled analgesia.