Developing and Deploying a Patient Safety Program in a Large Health Care Delivery System: You Can’t Fix What You Don’t Know About

Bagian, James P.; Lee, Caryl; Gosbee, John; DeRosier, Joseph; Stalhandske, Erik; Eldridge, Noel; Williams, Robert T.; Burkhardt, Mary

doi:10.1016/s1070-3241(01)27046-1

“…[353][354][355][356][357][358][359] Therefore, each facility should maintain records that track all adverse events and significant interventions, such as desaturation; apnea; laryngospasm; need for airway interventions, including the need for placement of supraglottic devices such as an oral airway, nasal trumpet, or LMA; positivepressure ventilation; prolonged sedation; unanticipated use of reversal agents; unplanned or prolonged hospital admission; sedation failures; inability to complete the procedure; and unsatisfactory sedation, analgesia, or anxiolysis. 360 Such events can then be examined for the assessment of risk reduction and improvement in patient/family satisfaction.…”

Section: Continuous Quality Improvementmentioning

confidence: 99%

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Coté¹,

Wilson²

2016

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The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age-and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, suffi cient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the

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“…As part of this process, the patient safety managers in each facility rate the severity and probability of harm of the event using a Safety Assessment Code (SAC) Matrix. 4 The SAC yields a rating from 1 to 3 for both actual events and close calls (in which significant harm could have been caused but was averted). Actual "SAC 3"-rated events have the highest severity of harm and all SAC 3 events, whether actual or potential, require a root cause analysis, while other lowerrisk events can be reported and documented in a briefer safety report.…”

Section: Root Cause Analysismentioning

confidence: 99%

Incorrect Surgical Procedures Within and Outside of the Operating Room

Neily

¹

,

Mills

²

,

Eldridge

³

et al. 2011

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Interventions:The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. Main Outcome Measures:The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm.Results: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P=.02). Reported close calls increased from 1.97 to 3.24 per month (P Յ.001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). Conclusions:The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

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“…[136][137][138][139][140] Therefore, each facility should maintain records that track adverse events such as desaturation, apnea, laryngospasm, the need for airway interventions including jaw thrust or positive pressure ventilation, prolonged sedation, unanticipated use of reversal agents, unintended or prolonged hospital admission, and unsatisfactory sedation/analgesia/anxiolysis. Such events can then be examined for assessment of risk reduction and improvement in patient satisfaction.…”

Section: Continuous Quality Improvementmentioning

confidence: 99%

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update

Coté¹,

Wilson²

2006

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The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age-and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children. INTRODUCTIONInvasive diagnostic and minor surgical procedures on pediatric patients outside the traditional operating room setting have increased in the last decade. As a consequence of this change and the increased awareness of the importance of providing analgesia and anxiolysis, the need for sedation for procedures in physician offices, dental offices, subspecialty procedure suites, imaging facilities, emergency departments, and ambulatory surgery centers has also markedly increased. In recognition of this need for both elective and emergency use of sedation in nontraditional

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Developing and Deploying a Patient Safety Program in a Large Health Care Delivery System: You Can’t Fix What You Don’t Know About

Cited by 155 publications

References 1 publication

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Incorrect Surgical Procedures Within and Outside of the Operating Room

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update

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