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1.
BMJ Open ; 10(5): e033336, 2020 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-32430447

RESUMO

OBJECTIVE: To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care. DESIGN: Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting. SETTING: Cardiac surgical unit in New Zealand. PARTICIPANTS: Culturally diverse patients in hospital undergoing heart surgery. MAIN OUTCOMES: A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort. RESULTS: Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment. CONCLUSIONS: These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

2.
BMJ Open ; 10(2): e032997, 2020 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-32079573

RESUMO

INTRODUCTION: NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals. METHODS AND ANALYSIS: Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews. ETHICS AND DISSEMINATION: We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143). TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.

3.
BMJ Open ; 9(10): e027122, 2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31676641

RESUMO

AIM: NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff - including the challenges they faced - in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation. METHOD: We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning. RESULTS: Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs. CONCLUSION: Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

6.
Trials ; 20(1): 342, 2019 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-31182142

RESUMO

BACKGROUND: Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Maori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces. METHODS: We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental "champions". Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle. DISCUSSION: If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000407291 . Registered on 21 March 2018.


Assuntos
Anestesistas , Controle de Infecções/métodos , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise por Conglomerados , Coleta de Dados , Higiene das Mãos , Humanos , Estudos Multicêntricos como Assunto , Projetos de Pesquisa , Tamanho da Amostra , Infecção da Ferida Cirúrgica/prevenção & controle
8.
Surg Endosc ; 33(7): 2061-2071, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30937619

RESUMO

BACKGROUND: Patient-reported outcome (PRO) measures (PROMs) are increasingly used as endpoints in surgical trials. PROs need to be consistently measured and reported to accurately evaluate surgical care. Laparoscopic cholecystectomy (LC) is a commonly performed procedure which may be evaluated by PROs. We aimed to evaluate the frequency and consistency of PRO measurement and reporting after LC. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting PROs of LC, between 2013 and 2016. Data on the measurement and reporting of PROs were extracted. RESULTS: A total of 281 studies were evaluated. Forty-five unique multi-item questionnaires were identified, most of which were used in single studies (n = 35). One hundred and ten unique rating scales were used to assess 358 PROs. The visual analogue scale was used to assess 24 different PROs, 17 of which were only reported in single studies. Details about the type of rating scale used were not given for 72 scales. Three hundred and twenty-three PROs were reported in 162 studies without details given about the scale or questionnaire used to evaluate them. CONCLUSIONS: Considerable variation was identified in the choice of PROs reported after LC, and in how they were measured. PRO measurement for LC is focused on short-term outcomes, such as post-operative pain, rather than longer-term outcomes. Consideration should be given towards the development of a core outcome set for LC which incorporates PROs.

9.
BMJ Open ; 9(3): e027258, 2019 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-30862638

RESUMO

OBJECTIVE: To capture and better understand patients' experience during their healthcare journey from hospital admission to discharge, and to identify patient suggestions for improvement. DESIGN: Prospective, exploratory, qualitative study. Patients were asked to complete an unstructured written diary expressed in their own words, recording negative and positive experiences or anything else they considered noteworthy. PARTICIPANTS AND SETTING: Patients undergoing vascular surgery in a metropolitan hospital. PRIMARY OUTCOME MEASURES: Complete diary transcripts underwent a general inductive thematic analysis, and opportunities to improve the experience of care were identified and collated. RESULTS: We recruited 113 patients in order to collect 80 completed diaries from 78 participants (a participant response rate of 69%), recording patients' experiences of their hospital-stay journey. Participating patients were a median (range) age of 69 (21-99) years and diaries contained a median (range) of 197 (26-1672) words each. Study participants with a tertiary education wrote more in their diaries than those without-a median (range) of 353.5 (48-1672) vs 163 (26-1599) words, respectively (Mann-Whitney U test, p=0.001). Three primary and eight secondary themes emerged from analysis of diary transcripts-primary themes being: (1) communication as central to care; (2) importance of feeling cared for and (3) environmental factors shaping experiences. In the great majority, participants reported positive experiences on the hospital ward. However, a set of 12 patient suggestions for improvement were identified, the majority of which could be addressed with little cost but result in substantial improvements in patient experience. Half of the 12 suggestions for improvement fell into primary theme 1, concerning opportunities to improve communication between healthcare providers and patients. CONCLUSIONS: Unstructured diaries completed in a patient's own words appear to be an effective and simple approach to capture the hospital-stay experience from the patient's own perspective, and to identify opportunities for improvement.

11.
BMJ Open ; 9(1): e022625, 2019 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-30782682

RESUMO

OBJECTIVES: To extend reliability of WHO Behaviourally Anchored Rating Scale (WHOBARS) to measure the quality of WHO Surgical Safety Checklist administration using generalisability theory. In this context, extending reliability refers to establishing generalisability of the tool scores across populations of teams and raters by accounting for the relevant sources of measurement errors. DESIGN: Cross-sectional random effect measurement design assessing surgical teams by the five items on the three Checklist phases, and at three sites by two trained raters simultaneously. SETTING: The data were collected in three tertiary hospitals in Auckland, New Zealand in 2016 and included 60 teams observed in 60 different cases with an equal number of teams (n=20) per site. All elective and acute cases (adults and children) involving surgery under general anaesthesia during normal working hours were eligible. PARTICIPANTS: The study included 243 surgical staff members, 138 (50.12%) women. MAIN OUTCOME MEASURE: Absolute generalisability coefficient that accounts for variance due to items, phases, sites and raters for the WHOBARS measure of the quality of WHO Surgical Safety Checklist administration. RESULTS: The WHOBARS in its present form has demonstrated good generalisability of scores across teams and raters (G absolute=0.83). The largest source of measurement error was the interaction between the surgical team and the rater, accounting for 16.7% (95% CI 16.4 to 16.9) of the total variance in the data. Removing any items from the WHOBARS led to a decrease in the overall reliability of the instrument. CONCLUSIONS: Assessing checklist administration quality is important for promoting improvement in its use, and WHOBARS offers a reliable approach for doing this.


Assuntos
Lista de Checagem/estatística & dados numéricos , Segurança do Paciente/normas , Melhoria de Qualidade/organização & administração , Centro Cirúrgico Hospitalar/organização & administração , Atitude do Pessoal de Saúde , Estudos Transversais , Humanos , Nova Zelândia , Variações Dependentes do Observador , Melhoria de Qualidade/normas , Reprodutibilidade dos Testes , Centro Cirúrgico Hospitalar/normas , Organização Mundial da Saúde
14.
BMJ Open ; 8(12): e022882, 2018 12 16.
Artigo em Inglês | MEDLINE | ID: mdl-30559155

RESUMO

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration. DESIGN: Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews. PARTICIPANTS: OR staff in three New Zealand hospitals. OUTCOME MEASURES: Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration. RESULTS: Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. CONCLUSIONS: The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.


Assuntos
Lista de Checagem/estatística & dados numéricos , Administração Hospitalar/normas , Segurança do Paciente/normas , Melhoria de Qualidade/organização & administração , Centro Cirúrgico Hospitalar/organização & administração , Atitude do Pessoal de Saúde , Humanos , Nova Zelândia , Variações Dependentes do Observador , Melhoria de Qualidade/normas , Reprodutibilidade dos Testes , Centro Cirúrgico Hospitalar/normas
15.
J Extra Corpor Technol ; 50(4): 225-230, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30581229

RESUMO

Although recent trials comparing on vs. off-pump revascularization techniques describe cardiopulmonary bypass (CPB) as "conventional," inadequate description and evaluation of how CPB is managed often exist in the peer-reviewed literature. We identify and subsequently describe regional and center-level differences in the techniques and equipment used for conducting CPB in the setting of coronary artery bypass grafting (CABG) surgery. We accessed prospectively collected data among isolated CABG procedures submitted to either the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) or Perfusion Measures and outcomes (PERForm) Registry between January 1, 2014, and December 31, 2015. Variation in equipment and management practices reflecting key areas of CPB is described across 47 centers (ANZCPR: 9; PERForm: 38). We report average usage (categorical data) or median values (continuous data) at the center-level, along with the minimum and maximum across centers. Three thousand five hundred sixty-two patients were identified in the ANZCPR and 8,450 in PERForm. Substantial variation in equipment usage and CPB management practices existed (within and across registries). Open venous reservoirs were commonly used across both registries (nearly 100%), as were "all-but-cannula" biopassive surface coatings (>90%), whereas roller pumps were more commonly used in ANZCPR (ANZCPR: 85% vs. PERForm: 64%). ANZCPR participants had 640 mL absolute higher net prime volumes, attributed in part to higher total prime volume (1,462 mL vs. 1,217 mL) and lower adoption of retrograde autologous priming (20% vs. 81%). ANZCPR participants had higher nadir hematocrit on CPB (27 vs. 25). Minimal absolute differences existed in exposure to high arterial outflow temperatures (36.6°C vs. 37.0°C). We report substantial center and registry differences in both the type of equipment used and CPB management strategies. These findings suggest that the term "conventional bypass" may not adequately reflect real-world experiences. Instead of using this term, authors should provide key details of the CPB practices used in their patients.


Assuntos
Ponte de Artéria Coronária , Ponte Cardiopulmonar , Humanos , Sistema de Registros , Resultado do Tratamento
16.
N Z Med J ; 131(1482): 29-37, 2018 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-30235190

RESUMO

AIM: We set out to explore the question, what ethical challenges do medical students identify when asked to perform or observe a sensitive examination, given a historical background relevant to this context. METHOD: Thematic analysis of 21 Ethics Reports from 9 female and 12 male students. RESULTS: Overall 14 students undertook a sensitive examination without the patient's consent; three did not carry out a sensitive examination because of a lack of consent; and two students (or their senior colleagues) gained the patient's written consent for the student to undertake the examination. One patient refused the student's request for consent to perform a digital rectal examination; and in the final case, verbal consent was given by the patient for the student to observe a bimanual examination only. Three interrelated core themes arose from thematic analysis of the research question: systemic constraints on getting consent; internal conflicts of interest; and, power and hierarchy. CONCLUSIONS: A number of senior medical students at our institution disclosed observing or performing sensitive examinations on patients without the patients' knowledge or consent.


Assuntos
Ética Médica/educação , Consentimento Livre e Esclarecido/ética , Exame Físico/ética , Estudantes de Medicina , Educação de Graduação em Medicina , Docentes de Medicina , Humanos , Nova Zelândia , Cultura Organizacional , Educação de Pacientes como Assunto , Direitos do Paciente/legislação & jurisprudência
17.
N Z Med J ; 131(1479): 45-56, 2018 07 27.
Artigo em Inglês | MEDLINE | ID: mdl-30048432

RESUMO

AIMS: The New Zealand Surgical Site Infection Improvement (SSII) Programme was established in 2013 to reduce the incidence of surgical site infections (SSI) in publicly funded hip and knee arthroplasties in New Zealand hospitals. METHODS: The programme pursued a three-pronged strategy: 1. Surveillance of SSI with a nationwide system 2. Promotion of consistent adherence to evidence-based practices proven to reduce SSI 3. Monitoring and publicly reporting changed practice and outcome data. RESULTS: Between quarter 3 2013 and quarter 4 2016 there has been a nationwide increase in compliance with all process measures: correct timing for antibiotic prophylaxis; use of the recommended antibiotic in the recommended dose and alcohol-based skin antisepsis. The SSI rate in hip and knee arthroplasties has shown a significant improvement. The nationwide median rate has fallen to 0.91% since June 2015, compared with 1.36% during the baseline period of April 2013 to March 2014 (p<0.01). This equates to approximately 55 fewer infections between August 2015 and June 2017, savings of NZD$2.2 million in avoided treatment and avoided disability-adjusted life years (DALYs) of NZD$5 million. CONCLUSIONS: The introduction of a nationwide SSI reduction programme for hip and knee arthroplasties resulted in an increase in compliance across the country with best practice that was associated with a reduction in incidence of SSI since June 2015 from the baseline period of April 2013 to March 2014, sustained to June 2017.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Prática Profissional/normas , Melhoria de Qualidade , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/normas , Humanos , Nova Zelândia/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Resultado do Tratamento
18.
Health Policy ; 122(7): 783-790, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29887389

RESUMO

The end of life is often associated with increased use of healthcare services. This increased use can include over-medicalisation, or over-treatment with interventions designed to cure that are likely futile in people who are dying. This is an issue with medical, ethical, and financial dimensions, and has implications for health policy, funding and the structure of care delivery. We measured the annual use of nine pre-defined public healthcare services between 1 January 2008 and 31 December 2012 by elderly New Zealanders (65-99 years old) in their last year of life and compared it with that of the cohort of elderly New Zealanders who used healthcare in the period but did not die. We used linked, encrypted unique patient identifiers to reorganise and filter records in routinely collected national healthcare utilisation and mortality administrative datasets. We found that, in New Zealand, people do seem to use more of most health services in their last year of life than those of the same age who are not in their last year of life. However, as they advance in age, particularly after the age of 90, this difference diminishes for most measures, although it is still substantial for days spent in hospital as an inpatient, and for pharmaceutical dispensings.


Assuntos
Hospitalização/economia , Aceitação pelo Paciente de Cuidados de Saúde , Assistência Terminal/economia , Idoso , Estudos de Coortes , Morte , Feminino , Política de Saúde , Hospitais , Humanos , Masculino , Nova Zelândia
19.
Can J Anaesth ; 65(6): 698-708, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29736769

RESUMO

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a non-profit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.


Assuntos
Anestesia/normas , Anestesiologia/normas , Segurança do Paciente/normas , Anestesia/efeitos adversos , Anestesia/métodos , Anestesiologia/economia , Dióxido de Carbono/sangue , Lista de Checagem , Pessoal de Saúde/normas , Humanos , Intubação Intratraqueal/normas , Monitorização Intraoperatória/normas , Sociedades Médicas , Organização Mundial da Saúde
20.
Anesth Analg ; 126(6): 2047-2055, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29734240

RESUMO

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.


Assuntos
Anestesia/normas , Anestesiologistas/normas , Assistência à Saúde/normas , Internacionalidade , Sociedades Médicas/normas , Organização Mundial da Saúde , Anestesia/métodos , Assistência à Saúde/métodos , Humanos , Segurança do Paciente/normas
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