Managing unforeseen events in anesthesia: collective trade-off between “understanding” and “doing”

Cuvelier, Lucie; Falzon, Pierre; Granry, J.C.; Moll, Marie-Christine

doi:10.3233/wor-2012-0417-1972

Cited by 8 publications

(10 citation statements)

References 20 publications

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“…4 Patient safety, however, continues to be a challenge for institutions and providers who deal with complex systems, high workload, time pressures, advanced technology, and environmental disturbances. [5][6][7][8][9][10] In anesthesiology, adverse events, such as medication errors, complications with airway management, pacemaker interference, wrong-sided nerve blocks, and preventable deaths, occur despite efforts by multiple organizations. [11][12][13] Anesthesia providers face expected complications of practice daily.…”

Section: It Has Been Nearly 20 Years Since the Institute Of Medicine ...mentioning

confidence: 99%

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide

et al. 2019

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Objectives:The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.Methods: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018. Results:The distributed survey yielded a response rate of 69% (84/122).Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events.Conclusions: This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peerto-peer learning, communication, and proactive approaches to prevent future similar errors.

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Section: It Has Been Nearly 20 Years Since the Institute Of Medicine ...mentioning

confidence: 99%

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide

et al. 2019

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“…This assessment framework is the result of the combination of the RAG with the long‐proven “analytic hierarchy process,” and hereafter, it will be colloquially named AHP‐RAG . The original AHP‐RAG—the predecessor of the present work—has been tailored to the field of anaesthesia, which, among other health care specialties, over the years has become a sort of benchmark field about RE applied in medicine . The survey design process, being inherently iterative, needs some cycles to reach a reasonable power to gain enough insight on resilience (cf the second and third limitations); the latter, along with the rather large number of questions needed to build a RAG questionnaire, makes the data collection its major flaw.…”

Section: Introductionmentioning

confidence: 99%

A multicountry comparative survey about organizational resilience in anaesthesia

Falegnami

Bilotta

Pugliese

et al. 2018

Evaluation Clinical Practice

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Rationale, aims, and objectives:The application of resilience in health care requires the shift from a cause-effect approach to a systemic approach, yet few tools have been developed to measure resilience potential in this specific context. This study tests a resilience assessment grid (RAG) questionnaire to measure the resilience of anaesthesiologists, with a cross-country survey. Method:A study was conducted with an analytic hierarchy process (AHP) questionnaire containing 57 detailed questions; 16 nations and 172 respondents were involved in the study. The data were statistically analysed to identify insights from the questionnaire, main improvements for further assessment, and confirmation of the design of the questionnaire. The questionnaire reliability was assessed by Cronbach analysis. Weak items were identified by a detailed correlations analysis and through a weight-polarization matrix. Construct validity was confirmed by principal component analysis (PCA) and factor analysis (FA). Results:The α level of Cronbach analysis is 0.910. PCA and FA confirmed the absence of underlying unexpected factors, with less than 8% from the first factor and a total of just 54% of variability explained by 17 factors. Suggestions for revising the questionnaire ensue from the analysis, with improvements for the questionnaire's significance. Conclusion:The questionnaire shows the potential to assess proxy measures of resilience, even confirming the relevance of a structured weighting approach based on the AHP. The exemplar statistical cross-country analyses encourage the widespread use of a centralized resilience questionnaire to support standardized analyses and the diffusion of best practices among organizations.

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“…Anaesthetic teams also show resilient behaviours when coping with unforeseen events. 15 Anaesthetic teams differed in strategies to 'recover' and 'control' a situation involving a moved tracheal tube that disrupted oxygen supply. Some teams initially communicated in order to gain a shared understanding and identify the problem, and consequently, oxygenated and re-intubated.…”

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confidence: 99%

“…Some teams initially communicated in order to gain a shared understanding and identify the problem, and consequently, oxygenated and re-intubated. Other teams were more 'cautious', 15 and firstly recovered the situation by manual oxygenation before communicating on how to proceed. Opposed to the former, these teams also called other staff for help.…”

mentioning

confidence: 99%

“…14 With the traditional view, safety is a binary construct depending on identifying performance that is 'inadequate' and 'erroneous' compared with rules and established guidelines, whereas the assessment of safety from a resilience view depends on the conditions of the situation and the involved trade-offs in decision making. 15 Examining how anaesthetic practitioners create safety therefore offers a valuable contributory pathway for future research to complement the traditional 'error counting' approach.…”

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confidence: 99%

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