A quality improvement initiative using peer audit and feedback to improve compliance.

BACKGROUND: The Surgical Safety Checklist (SSC) published by the WHO in 2009 is used as standard in surgery worldwide to reduce perioperative patient mortality. However, compliance with the SSC and quality of its application are often not satisfactory. Internal audits and feedbacks seem promising for improving SSC application. OBJECTIVE: The purpose of this study is to investigate whether an intervention consisting of peer observation and immediate peer feedback can be implemented with high fidelity and acceptance. METHOD: Data were obtained from a national pilot programme that was initiated in Switzerland in 2018 to measure and improve compliance with the SSC using peer audit and feedback. A total of 11 hospitals with 14 sites implemented the full intervention. Each hospital formed an interprofessional project team that should perform at least 30 observations with feedback on SSC application documented in an observation tool developed specifically for this programme. Since the SSCs of the study hospitals differ greatly regarding checklist items, for each of the three SSC sections standard items were defined: four at Sign In, five at Team Time Out and two at Sign Out. Frequency analyses were performed for initiation characteristics, SSC application at item level, feedback characteristics and programme evaluation. RESULTS: The 11 hospitals documented 715 valid observations, and feedback on SSC application was provided for 79% of the observations. In 61%, all team members stopped their work for the SSC application, and in 71%, the items were read off from the checklist (instead of recalled from memory). On average, 86% of the standard items were read out by the checklist coordinator, whilst the two items at Sign Out were read out only in 60% and 74%. Additional visual checks with another source (e.g. patient wristband) took place in only 41%, and verbal confirmation of the items (by someone else other than the checklist coordinator) was obtained on an average of 76% across all three checklist sections. The surgical teams reacted positively in 64% to the peer feedback. CONCLUSION: Both implementation fidelity and acceptability of the intervention were high-the present intervention seems suitable for regular monitoring of the quality of SSC application with internal resources. Peer observation facilitated identifying weaknesses regarding the SSC process and application at item level. Across all hospitals, the Sign Out section in general, visual control for item checks and lack of work interruption of all team members during SSC application showed up as the main areas of improvement.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology.

: The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Enhancing the quality and safety of the perioperative patient.

PURPOSE OF REVIEW: Many possible hazards bedevil the perioperative patient. This review focuses on a number of aspects of perioperative management where the patient's quality and safety can be enhanced. RECENT FINDINGS: Our understanding of the relationship between preoperative preparation and postoperative outcomes has improved. There have also been recent developments in our understanding of how to construct useful cognitive aids and make the best use of checklists by understanding the cultural environment supporting their use. Postoperatively, the concept of 'failure to rescue' in the surgical patients has been explored. SUMMARY: A clear vision of what postoperative recovery should mean for practitioner and patients; careful risk stratification and prophylactic measures to avoid postoperative complications; the judicious use of checklists and other cognitive aids to complement clinical expertise in promoting safety within each local context; and the prompt recognition and rescue of postoperative problems when they occur are all important aspects of a safe perioperative care.

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

BACKGROUND: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). METHODS: A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. RESULTS: One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60). CONCLUSIONS: This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

Safety-II and resilience: the way ahead in patient safety in anaesthesiology.

PURPOSE OF REVIEW: Anaesthesiology is a specialty with a remarkable track record regarding improvements in safety. Nevertheless, modern healthcare poses increasing demands on quality and outcome: more complexity, more patients with increasing risk-factors, more regulation from society concerning quality and outcome and finally more demand of the stakeholders for efficiency. This leads us to ask the question if our traditional way of handling 'risk' and 'safety' will stand the challenges of the future? RECENT FINDINGS: Most of the success of modern anaesthesiology results from improved technology, pharmacology, training and education, improved systems, focus on human performance as well as standardization and development of guiding information. All of these aspects are crucial and have their relevance for well tolerated and modern practice. But despite all of these achievements, we must face the fact that we still cannot control complex processes by application of linear thinking (standardization). Modern risk-management concepts in other ultra-safe systems such as civil aviation or air traffic control introduced the concept of 'resilience' as well as 'safety-II' in order to deal with the challenges of increasing complex conditions. SUMMARY: We are well advised to consider adapting these modern concepts of 'resilience' and 'safety-II' thinking when we want to substantially improve patient safety in anaesthesiology.

The role of the anesthesiologist in perioperative patient safety.

PURPOSE OF REVIEW: Despite the benefits of rapidly advancing therapeutic and diagnostic possibilities, the perioperative setting still exposes patients to significant risks of adverse events and harm. Anesthesiologists are in midstream of perioperative care and can make significant contributions to patient safety and patient outcomes. This article reviews recent research results outlining the current trends of perioperative patient harm and summarizes the evidence in favor of patient safety practices. RECENT FINDINGS: Adverse events and patient harm continue to be frequent in the perioperative period. Adverse events occur in about 30% of hospital admissions, are associated with higher mortality, and may be preventable in more than 50%. Evidence-based recommendations are available for many patient safety issues. No magic bullet practices exist, but promising targets include the prevention and limitation of perioperative infections and of complications of airway and respiratory management, the maintenance of achieved safety standards, the use of checklists, and others. SUMMARY: Current research provides growing evidence for the effectiveness of several patient safety practices designed to prevent or diminish perioperative adverse events and patient harm. Future investigations will hopefully fill the numerous persisting knowledge gaps.

The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.

PURPOSE OF REVIEW: Four years after the launch of the Helsinki Declaration on Patient Safety in Anaesthesiology, it is of interest to assess its role in European and Global Patient Safety efforts. RECENT FINDINGS: The Declaration is widely supported, not only in Europe, but also has attracted much attention and support globally. In Europe, it represented a major step in European-wide patient safety networking and initiatives. The European Patient Safety Task Force, created jointly by the European Board of Anaesthesiology and the European Society of Anaesthesiology, has developed useful monitoring and introduction tools. A new Patient Safety Committee is being introduced, and this will facilitate current and future initiatives. SUMMARY: The launch of Helsinki Declaration of Patient Safety in Anaesthesiology in 2010 was a major step forward for patient safety initiatives in European and Global anesthesiology. Several steps have been taken in the 4 years that have passed, but the task needs continuous attention to ensure that every patient received the safest possible anesthesiology care.

A survey of standardised drug syringe label use in European anaesthesiology departments.

CONTEXT: Standardised drug syringe labelling may reduce drug errors, but data on drug syringe labelling use in European anaesthesiology departments are lacking. OBJECTIVES: Survey investigating if standardised drug syringe labelling is used, and if there are geographical, demographic and professional differences in hospitals with and without use of drug syringe labelling. DESIGN: Structured, web-based anonymised questionnaire. SETTING: European anaesthesia departments. PARTICIPANTS: Members of the European Society of Anaesthesiology. INTERVENTION: Online survey from 2 February to 12 April 2011. MAIN OUTCOME MEASURE: Standardised drug syringe labelling use and, if yes, drug syringe labelling for insulin and norepinephrine. METHODS: Descriptive and comparative analyses of users and nonusers of standardised drug syringe labelling. RESULTS: One thousand and sixty-four of 4163 members (25.6%) from 72 countries participated, among whom 660 (62.0%) used standardised drug syringe labelling; in Northern and Western Europe, there were 428 users of drug syringe labelling and 112 nonusers, and in Southern and Eastern Europe, there were 184 users and 255 nonusers (P < 0.001). Three hundred and ninety-four (37%) respondents used standardised drug syringe labelling hospital-wide; 202 (30.1%) used International Organisation of Standardisation-based standardised drug syringe labelling, 101 (15.1%) used similar systems, 278 (41.5%) used other systems and 89 (13.3%) used labels supplied by drug manufacturers. The label colour for insulin was reported as white or 'none' in 519 (76.7%) answers and another colour in 158 (23.3%). The label colour for norepinephrine was reported as violet in 206 (30.4%) answers, white or 'none' in 226 (33.3%), red in 114 (16.8%) and another colour in 132 (19.5%). A standardised drug syringe labelling system supplied by the pharmaceutical industry was supported by 819 (76.9%) respondents, and not supported by 227 (21.3%). CONCLUSION: A majority of European anaesthesiology departments used standardised drug syringe labelling, with regional differences and mostly without following an international standard. Thus, there are options for quality improvement in drug syringe labelling.

A Swiss anaesthesiology closed claims analysis: report of events in the years 1987-2008.

BACKGROUND AND OBJECTIVE: In 1999, the Swiss Society of Anaesthesiology and Reanimation (SSAR) initiated an analysis of closed malpractice claims filed against anaesthetists in a project intended to improve patient safety. This article discusses the results of a review of closed claims between 1987 and 2008 and filed up to the end of 2009. METHODS: Records of closed claims were provided by Swiss professional medical liability insurance companies and the Office for Extrajudicial Expert Review of the Swiss Medical Association. Data were collected by an onsite reviewer, converted into a standardised format and sent to the SSAR Closed Claims Study Group.Assessment criteria employed by the committee were level of care (standard or substandard); severity of injury; appropriateness of patient information; and consent. RESULTS: The records of 171 events leading to anaesthesia-related injuries were entered into the database. These injuries occurred within the period 1987-2008. The majority of claims (54%) were related to regional anaesthesia, with general anaesthesia accounting for 28% and other anaesthesia-related procedures for 18%. The quality of care was judged by the committee to be substandard in 55% of cases, and liability was accepted in 46% of all claims. Negative outcomes were death in 12% and permanent injury in 63% of the patients. CONCLUSION: The closed claims analysis project enabled the SSAR to identify areas of high medicolegal risks to gain an insight into the causes of infrequent but potentially harmful events leading to anaesthesia-related injuries and, based on these data, to develop preventive strategies.

Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology.

The purpose of these guidelines on the preoperative evaluation of the adult non-cardiac surgery patient is to present recommendations based on available relevant clinical evidence. The ultimate aims of preoperative evaluation are two-fold. First, we aim to identify those patients for whom the perioperative period may constitute an increased risk of morbidity and mortality, aside from the risks associated with the underlying disease. Second, this should help us to design perioperative strategies that aim to reduce additional perioperative risks. Very few well performed randomised studies on the topic are available and many recommendations rely heavily on expert opinion and are adapted specifically to the healthcare systems in individual countries. This report aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of subcommittees of scientific subcommittees and individual members of the ESA. Electronic databases were searched from the year 2000 until July 2010 without language restrictions. These searches produced 15 425 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Scottish Intercollegiate Guidelines Network grading system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Anesthesia and patient safety: have we reached our limits?

PURPOSE OF REVIEW: To provide recent evidence of safety in anesthesia and appraise the role of established tools of safety improvement in anesthesia practice. RECENT FINDINGS: The current incidence of minor events or complications during anesthesia is estimated at 18-22%, for severe complications 0.45-1.4%, and for mortality of 1: 100 000. Evidence suggests that despite such low complication rates, further improvements can still be made by addressing systemic factors which are known to set up conditions for adverse events. In particular, improvements can be made in the areas of drug errors, and inadequate or lack of communication between different clinical teams during the process of handovers. In addition, the evidence is growing which highlights the importance of established tools such as critical incident reporting, quality management using plan-do-check-act cycles, use of checklists and use of simulation in training clinical staff in the areas of nontechnical skills. SUMMARY: Anesthesia is one of the safest clinical specialties and remains at the top among leaders of patient safety. This review provides evidence for the areas in which further progress can be made, and usefulness of certain tools, such as critical incident reporting, checklists, plan-do-check-act cycles and simulation, can be used for continued improvements.

The Helsinki Declaration on Patient Safety in Anaesthesiology.

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.