Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

SummaryHeart failure is a major risk factor for adverse postoperative events following non-cardiac surgery. The use of transthoracic echocardiogram as a pre-operative investigation to assess cardiac dysfunction has limitations in this setting. The N-Terminal fragment of B-Type natriuretic peptide (NT proBNP) has been used in screening for heart failure. We have investigated the use of NT proBNP as a screening tool for left ventricular systolic dysfunction to reduce the requirement for preoperative echocardiograms. Ninety-eight pre-operative non-cardiac surgical patients scheduled to undergo echocardiography were assessed clinically and with an NT proBNP measurement. Echocardiogram was used to define two groups of patients depending on the presence or absence of abnormal left ventricular function and the NT proBNP level was compared between the groups using non-parametric and receiver-operator-characteristic (ROC) curve analysis. In terms of preoperative screening, a NT proBNP of <38.2 pmol.l )1 had a 100% negative predictive value in predicting patients with normal left ventricular systolic function and would have prevented the requirement for echocardiogram in 43% of pre-operative patients. NT proBNP was superior to electrocardiological and clinical criteria for detection of a normal echocardiogram. This may have significant impact in the pre-operative assessment of patients undergoing non-cardiac surgery. Heart failure involving left ventricular systolic dysfunction (LVSD) is a major risk factor for adverse peri-operative cardiovascular events [1]. Pre-operative recognition of LVSD is an important component of anaesthetic assessment. However, patients with cardiac dysfunction are often asymptomatic and where symptoms do exist they may be relatively non-specific. One investigational approach is to use indices determined by the use of resting transthoracic echocardiogram (TTE) for the assessment of cardiac dysfunction. In many centres this is seen as the 'gold standard' non-invasive pre-operative test. However, there are clinical and practical disadvantages associated with this simple investigational approach. The decision to obtain an echocardiogram is based on various pre-operative criteria which may vary between clinicians and are not consistently associated with subsequent abnormalities on echocardiogram. TTE is also relatively expensive and in many centres has a significant waiting list for its availability, since other specialties with more direct evidence for the use of TTE compete with pre-operative services for its availability.It follows that the ability of a biochemical marker to reliably and rapidly screen for cardiac dysfunction in patients presenting for major surgery would have considerable benefit both in reducing the requirement for preoperative TTE and assisting in the anaesthetic assessment of these patients.

The effect of repeated audit on the quality of transfer of brain-injured patients into a regional neurosciences centre PB Messer, AC Sweenie, RJ Whittle, IM McEleavy Brain injury is common and transfer of such patients to a neuroscience centre is a frequently occurring event. Transfer is a time of potential instability and can contribute to physiological changes that could cause secondary brain injury. UK data suggest that there has been a gradual improvement in quality and outcome of transfers of brain-injured patients during the last three decades. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) have published guidelines to improve the safety and quality of transfers. Over a seven-year period, we audited transfers four times and implemented three successive interventions aimed at improving the quality of transfers of brain-injured patients into the regional neurosciences centre. We observed a significant improvement in the transfer of patients according to AAGBI guidelines across most domains of patient care. The use of repeated cycles of audit and intervention significantly improved the quality of transfer of brain-injured patients, which could improve patient safety and outcome.

No abstract