Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned

Abstract

This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Reporting and responding to patient safety incidents based on data from hospitals’ reporting systems: A systematic review

“…[15,19,21] Three studies reported adverse drug events and reactions (side effect/interaction) as medication-related incidents. [13,18,27] Medication-related incidents were the highestrated [14,19,24] or second highest-rated concern [20,21,26,27] in seven studies out of twelve. Five studies reported general trends in medication-related incidents without describing them in detail.…”

“…Sixteen (n = 16) papers were included in the final analysis. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] We conducted the study selections with three researchers independently examining each paper phase by phase. Discussions were held to compare the selections, and in the case of disagreement, the decision about inclusion or exclusion was carried out through consensus.…”

“…Medication-related incidents were incidents with failures in medication administration principles. This include incidents involving the wrong medication, [15,20,24,27] patient, [15,20] dose, [13,15,20,21,24] time [20] or route [14,15,20] and medicine administered with the wrong speed [15,24,27] or not administered at all. [15,19,21] Three studies reported adverse drug events and reactions (side effect/interaction) as medication-related incidents.…”

Conhecimento de acadêmicos de enfermagem sobre os cuidados do enfermeiro ao paciente em recuperação anestésica

“…Ante a ocorrência de falhas técnicas e/ou de habilidades não técnicas que contribuem para a ocorrência de eventos adversos em anestesia 3 , associados a alterações sistêmicas do paciente no pós-operatório, as quais o predispõe a complicações de origem circulatória, respiratória e gastrointestinal 4 , torna-se necessário à equipe de saúde, especialmente à enfermagem, precisão na avaliação clínica, a fim de identificar alterações hemodinâmicas e favorecer a qualidade e a segurança assistencial 5 .…”

“…Estudo conduzido com relatórios de incidentes em hospitais dos Estados Unidos identificou que, na análise de causa raiz de 36 eventos adversos, os erros foram causados por falhas de padronização e/ou política em processos para a administração segura de anestésicos 3 . Esses fatores podem potencializar a ocorrência de complicações, como: hipotermia, hipoxemia, apneia, tremores, náuseas, vômitos, disritmias cardíacas e retenção urinária.…”