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1.  Assessing system failures in operating rooms and intensive care units 
Background
The current awareness of the potential safety risks in healthcare environments has led to the development of largely reactive methods of systems analysis. Proactive methods are able to objectively detect structural shortcomings before mishaps and have been widely used in other high‐risk industries.
Methods
The Leiden Operating Theatre and Intensive Care Safety (LOTICS) scale was developed and evaluated with respect to factor structure and reliability of the scales. The survey was administered to the staff of operating rooms at two university hospitals, and intensive care units (ICUs) of one university hospital and one teaching hospital. The response rate varied between 40–47%. Data of 330 questionnaires were analysed. Safety aspects between the different groups were compared.
Results
Factor analyses and tests for reliability resulted in nine subscales. To these scales another two were added making a total of 11. The reliability of the scales varied from 0.75 to 0.88. The results clearly showed differences between units (OR1, OR2, ICU1, ICU2) and staff.
Conclusion
The results seem to justify the conclusion that the LOTICS scale can be used in both the operating room and ICU to gain insight into the system failures, in a relatively quick and reliable manner. Furthermore the LOTICS scale can be used to compare organisations to each other, monitor changes in patient safety, as well as monitor the effectiveness of the changes made to improve the level of patient safety.
doi:10.1136/qshc.2005.015446
PMCID: PMC2464926  PMID: 17301205
2.  Improving hospital staff compliance with environmental cleaning behavior 
Reducing the incidence of healthcare-associated infections requires proper environmental cleanliness of frequently touched objects within the hospital environment. An intervention was launched in June 2012 and repeated in February 2013 and August 2013 to increase hospital room cleanliness with repeated education and training of nursing and environmental services staff to reduce healthcare-associated infections at Cook Children's Medical Center. Random rooms were tested, staff were trained about proper cleaning, rooms were retested for surface cleanliness, and preintervention and postintervention values were compared. The percentage of cleaned surfaces improved incrementally between the three trials—with values of 20%, 49%, and 82% showing that repeat training favorably changed behavior in the staff (P = 0.007). During the study period, during which other infection control interventions were also introduced, there was a decline from 0.27 to 0.21 per 1000 patient days for Clostridium difficile infection, 0.43 to 0.21 per 1000 patient days for ventilator-associated infections, 1.8% to 1.2% for surgical site infections, and 1.2 to 0.7 per 1000 central venous line days for central line–associated bloodstream infections.
PMCID: PMC3954653
3.  Improving operating room safety 
Despite the introduction of the Universal Protocol, patient safety in surgery remains a daily challenge in the operating room. This present study describes one community health system's efforts to improve operating room safety through human factors training and ultimately the development of a surgical checklist. Using a combination of formal training, local studies documenting operating room safety issues and peer to peer mentoring we were able to substantially change the culture of our operating room. Our efforts have prepared us for successfully implementing a standardized checklist to improve operating room safety throughout our entire system. Based on these findings we recommend a multimodal approach to improving operating room safety.
doi:10.1186/1754-9493-3-25
PMCID: PMC2784747  PMID: 19930577
4.  Systematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions 
BMJ quality & safety  2013;22(6):485-494.
Background
Teamwork—that is, collaboration and communication—is an important factor for safe healthcare, but professions perceive the quality of teamwork differently.
Objective
To examine the relationship between simulation-based team training (SBTT) and different professions’ self-efficacy, experienced quality of collaboration and communication, perceptions of teamwork and safety, together with staff turnover.
Methods
All staff (n=151; physicians, nurses and nurse assistants) in an intensive care unit (ICU) at a university hospital were systematically trained over 2 years. Data on individual self-efficacy were measured using the self-efficacy questionnaire; the experienced quality of collaboration and communication, teamwork climate, safety climate and perception of working conditions were sampled using the ICU version of the safety attitudes questionnaire (SAQ). Staff turnover and sick leave was measured using the hospital's staff administration system for the intervention ICU and a control ICU in the same hospital.
Results
The perception of safety differed between professions before training. Nurses’ and physicians’ mean self-efficacy scores improved, and nurse assistants’ perceived quality of collaboration and communication with physician specialists improved after training. Nurse assistants’ perception of the SAQ factors teamwork climate, safety climate and working conditions were more positive after the project as well as nurses’ perception of safety climate. The number of nurses quitting their job and nurse assistants’ time on sick leave was reduced in comparison to the control ICU during the study period.
Limitations
Results for SAQ factors must be interpreted with caution given that Cronbach's α and inter-correlations for the SAQ factors showed lower values than benchmarking data.
Conclusions
All team members benefited from the SBTT in an authentic composed team, but this was expressed differently for the respective professions.
doi:10.1136/bmjqs-2012-000994
PMCID: PMC3711495  PMID: 23412932
Team training; Crew resource management; Critical care; Safety culture; Simulation
5.  Perioperative considerations for patient safety during cosmetic surgery – preventing complications 
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeon’s practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.
A review of the Joint Commission’s Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.
After review of the present paper, the reader should be able to introduce the Joint Commission’s Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patient’s experience and surgical outcome.
PMCID: PMC2705307  PMID: 20190907
Body contouring surgery; Cosmetic surgery; Patient safety
6.  A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital 
Quality & safety in health care  2005;14(2):123-129.


Problem: When patient safety programs were mandated for Japanese health care institutions, a safety culture, a tool for collecting incident reports, an organizational arrangement for multidisciplinary collaboration, and interventional methods for improvement had to be established.
Design: Observational study of effects of new patient safety programs.
Setting: Osaka University Hospital, a large government-run teaching hospital.
Strategy for change: A voluntary and anonymous web-based incident reporting system was introduced. For the new organizational structure a clinical risk management committee, a department of clinical quality management, and area clinical risk managers were established with their respective roles clearly defined to advance the plan-do-study-act cycle and to integrate efforts. For preventive action, alert procedures, staff education, ward rounds by peers, a system oriented approach for reducing errors, and various feedback channels were introduced.
Effects of change: Continuous incident reporting by all hospital staff has been observed since the introduction of the new system. Several error inducing situations have been improved: wrong choice of drug in computer prescribing, maladministration of drugs due to a look-alike appearance or confusion about the manipulation of a medical device, and poor after hours service of the blood transfusion unit. Staff participation in educational seminars has been dramatically improved. Ward rounds have detected problematic procedures which needed to be dealt with.
Lessons learnt: Patient safety programs based on a web-based incident reporting system, responsible persons, staff education, and a variety of feedback procedures can help promote a safety culture, multidisciplinary collaboration, and strong managerial leadership resulting in system oriented improvement.
doi:10.1136/qshc.2003.008607
PMCID: PMC1743978  PMID: 15805458
7.  Highly Reliable Procedural Teams: The Journey to Spread the Universal Protocol in Diagnostic Imaging 
The Permanente Journal  2014;18(1):33-37.
The Joint Commission’s Universal Protocol has been widely implemented in surgical settings since publication in 2003, and the elements are applied to procedures occurring in other health care arenas, in particular, diagnostic imaging. The teams underwent human factors training and then adapted key interventions used in surgical suites to their workflows. Perception of the safety climate improved 25% in interventional radiology and 4.5% in mammography. Perception of the teamwork climate decreased 5.4% in interventional radiology and 16.6% in mammography. The study reveals unexpected challenges and requires long-term effort and focus.
Context:
The Joint Commission’s Universal Protocol has been widely implemented in surgical settings since publication in 2003. The elements improved patient safety in operating rooms, and the same rigor is being applied to procedures occurring in other health care arenas, in particular, diagnostic imaging.
Objective:
In 2011, Kaiser Permanente West Los Angeles’s Diagnostic Imaging Department desired to adapt previous work on Universal Protocol implementation to improve patient safety in interventional radiology and mammography procedures.
Design:
The teams underwent human factors training and then adapted key interventions used in surgical suites to their workflows. Time-out posters, use of whiteboards, “glitch books,” and regular audits provided structure to overcome the risks that human factors present.
Main Outcome Measures:
Staff and physician perceptions of the teamwork and safety climates in their modalities were measured using the Safety Attitudes Questionnaire at baseline and at 18 months after training. Unusual Occurrence Reports were also reviewed to identify events and near misses that could be prevented. Implementation of key process changes were identified as process measures.
Results:
Perception of the safety climate improved 25% in interventional radiology and 4.5% in mammography. Perception of the teamwork climate decreased 5.4% in interventional radiology and 16.6% in mammography. Unusual occurrences were underreported at baseline, and there is ongoing reluctance to document near misses.
Conclusion:
This work provides important considerations of the impact of departmental cultures for the implementation of the Universal Protocol in procedural areas. It also reveals unexpected challenges, and requires long-term effort and focus.
doi:10.7812/TPP/13-071
PMCID: PMC3951028  PMID: 24626070
8.  Start time delays in operating room: Different perspectives 
Saudi Journal of Anaesthesia  2011;5(3):286-288.
Background:
Healthcare expenditure is a serious concern, with escalating costs failing to meet the expectations of quality care. The treatment capacities are limited in a hospital setting and the operating rooms (ORs). Their optimal utilization is vital in efficient hospital management. Starting late means considerable wait time for staff, patients and waste of resources. We planned an audit to assess different perspectives of the residents in surgical specialities and anesthesia and OR staff nurses so as to know the causative factors of operative delay. This can help develop a practical model to decrease start time delays in operating room (ORs).
Aims:
An audit to assess different perspectives of the Operating room (OR) staff with respect to the varied causative factors of operative delay in the OR. To aid in the development of a practical model to decrease start time delays in ORs and facilitate on-time starts at Jai Prakash Narayan Apex Trauma centre (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi.
Methods:
We prepared a questionnaire seeking the five main reasons of delay as per their perspective.
Results:
The available data was analysed. Analysis of the data demonstrated the common causative factors in start time operative delays as: a lack of proper planning, deficiencies in team work, communication gap and limited availability of trained supporting staff.
Conclusions:
The preparation of the equipment and required material for the OR cases must be done well in advance. Utilization of newer technology enables timely booking and scheduling of cases. Improved inter-departmental coordination and compliance with preanesthetic instructions needs to be ensured. It is essential that the anesthesiologists perform their work promptly, well in time . and supervise the proceedings as the OR manager. This audit is a step forward in defining the need of effective OR planning for continuous quality improvement.
doi:10.4103/1658-354X.84103
PMCID: PMC3168346  PMID: 21957408
Delay; operative; perspectives; start time
9.  Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study 
BJA: British Journal of Anaesthesia  2013;110(5):807-815.
Background
Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital.
Methods
We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture.
Results
The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors ‘frequency of events reported’ and ‘adequate staffing’ with regression coefficients at −0.25 [95% confidence interval (CI), −0.47 to −0.07] and 0.21 (95% CI, 0.07–0.35), respectively. Overall, the intervention group reported significantly more positive culture scores—including at baseline.
Conclusions
Implementation of the SSC had rather limited impact on the safety culture within this hospital.
doi:10.1093/bja/aet005
PMCID: PMC3630285  PMID: 23404986
checklist; safety; safety climate; safety culture; surgery
10.  Reduction of Laparoscopic-Induced Hypothermia, Postoperative Pain and Recovery Room Length of Stay by Pre-Conditioning Gas with the Insuflow® Device: A Prospective Randomized Controlled Multi-Center Study 
Objective:
To assess the efficacy and safety of Insuflow® (Georgia BioMedical, Inc.) filter heater hydrator device in reducing the incidence, severity and extent of hypothermia, length of recovery room stay and postoperative pain at the time of laparoscopy.
Design:
Prospective, randomized, blinded, controlled multi-center study. Patients underwent gynecologic procedures via laparoscopy; surgeons, anesthesiologists and recovery room personnel assessed the results.
Setting:
Seven North American institutions.
Patients:
Seventy-two women for safety evaluation and efficacy studies.
Interventions:
Intraoperative pre-conditioning of laparoscopic gas with the Insuflow® device (treatment) or standard raw gas (control) during laparoscopic surgery and postoperatively.
Main Outcome Measures:
Incidence, severity and extent of hypothermia, postoperative pain perception and length of recovery room stay.
Results:
The Insuflow® group had significantly less intra-operative hypothermia, reduced length of recovery room stay and reduced postoperative pain. Pre-conditioning of laparoscopic gas by filtering heating and hydrating was well tolerated with no adverse effects. The safety profile of the Insuflow® pre-conditioned gas showed significant benefits compared to currently used raw gas.
Conclusions:
Pre-conditioning laparoscopic gas by filtering heating and hydrating with the Insuflow® device was significantly more effective than the currently used standard raw gas and was safe in reducing or eliminating laparoscopic-induced hypothermia, shortening recovery room length of stay and reducing postoperative pain.
PMCID: PMC3015252  PMID: 10036122
Gas hydration; Laparoscopic hypothermia; Pain; Length of stay; Laparoscopy; Peritoneum
11.  Anaesthetic complications in plastic surgery 
Anaesthesia related complications in plastic surgeries are fortunately rare, but potentially catastrophic. Maintaining patient safety in the operating room is a major concern of anaesthesiologists, surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential and pressure to avoid these complications in cosmetic surgery is increasing. Key aspects of patient safety in the operating room are outlined, including patient positioning, airway management and issues related to some specific conditions, essential for minimizing post-operative morbidity. Risks associated with extremes of age in the plastic surgery population, may be minimised by a better understanding of the physiologic changes as well as the pre-operative and post-operative considerations in caring for this special group of patients. An understanding of the anaesthesiologist's concerns during paediatric plastic surgical procedures can facilitate the coordination of efforts between the multiple services involved in the care of these children. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients’ experience and surgical outcome.
doi:10.4103/0970-0358.118626
PMCID: PMC3901926  PMID: 24501480
Anaesthesia; complications; plastic; surgery
12.  Laser safety: Risks, hazards, and control measures 
Laser Therapy  2011;20(2):95-106.
Now that laser technology has emerged from hospital operating rooms, and has become available to office practices, clinics, and private enterprises, the burden of responsibility for safety has shifted from hospital staff to the individual user, often without benefit of appropriate or adequate resources.
What remains, regardless of the practice site, application, or system in use, is the constant goal of establishing and maintaining a laser safe environment for the patient, the staff, and the user, at all times. This should be the goal of all who are involved with the sale, purchase, application, and management of all medical laser systems–under all circumstances.
Laser safety is EVERYONE'S concern! A laser is as safe or as hazardous as the user–and that user's knowledge and skill, defines how well laser safety is managed.
Of all hazards, complacency is the most dangerous, and it is imperative to develop a risk management perspective on laser safety. Proper safety management requires a fourfold approach including: knowledge of standards, identification of hazards and risks, implementation of appropriate control measures, and consistent program audit to demonstrate quality assurance.
doi:10.5978/islsm.20.95
PMCID: PMC3799025  PMID: 24155518
13.  Learning from adverse incidents involving medical devices 
BMJ : British Medical Journal  2002;325(7358):272-275.
Problem
The NHS is perceived to have a poor record of learning from incidents. Despite efforts of the Medical Devices Agency, which issues safety warnings, adverse incidents with medical devices continue to occur, some of which result in serious injury or death through device failures, user errors, and organisational problems.
Design
Introduction of feedback notes on a supportive investigation that seeks to determine latent factors, immediate triggers, causes, and positive actions taken by staff that minimised adverse consequences.
Background and setting
Medical physics department providing equipment management services in a major NHS teaching trust.
Key measures for improvement
Reduction in repetitions of adverse incidents and improved staff competency in using devices.
Strategy for change
A feedback note was developed to describe the incident and generic details of the equipment, summarise the investigation (focusing on latent causes and immediate triggers), and describe lessons to be learnt and positive actions by staff.
Effects of change
Feedback notes have been used in teaching sessions and given to ward link nurses. Despite being new, the positive supportive approach has encouraged an open reporting culture.
Lessons learnt
Adverse incidents are typically caused by alignment of different factors, but good practice can prevent errors becoming incidents. Careful analysis of incidents reveals both the multifactorial causes and the good practices that can help minimise repetitions.
PMCID: PMC1123780  PMID: 12153928
14.  Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children 
Canadian Journal of Surgery  2009;52(4):309-315.
Background
Wrong-site, wrong-procedure and wrong-patient surgeries are catastrophic events for patients, medical caregivers and institutions. Operating room (OR) briefings are intended to reduce the risk of wrong-site surgeries and promote collaboration among OR personnel. The purpose of our study was to evaluate 2 OR briefing safety initiatives, “07:35 huddles” (preoperative OR briefing) and “surgical time-outs” (perioperative OR briefing), at the Hospital for Sick Children in Toronto, Ont.
Methods
First, we evaluated the completion and components of the 07:35 huddles and surgical time-outs briefings using direct observations. We then evaluated the attitudes of the OR staff regarding safety in the OR using the “Safety Attitudes Questionnaire, Operating Room version.” Finally, we conducted personal interviews with OR personnel.
Results
Based on direct observations, 102 of 159 (64.1%) 07:35 huddles and 230 of 232 (99.1%) surgical time-outs briefings were completed. The perception of safety in the OR improved, but only among nurses. Regarding difficulty discussing errors in the OR, the nurses’ mean scores improved from 3.5 (95% confidence interval [CI] 3.2–3.8) prebriefing to 2.8 (95% CI 2.5–3.2) postbriefing on a 5-point Likert scale (p < 0.05). Personal interviews confirmed that, mainly among the nursing staff, pre-and perioperative briefing tools increase the perception of communication within the OR, such that discussions regarding errors within the OR are more encouraged.
Conclusion
Structured communication tools, such as 07:35 huddles and surgical time-outs briefings, especially for the nursing personnel, change the notion of individual advocacy to one of teamwork and being proactive about patient safety.
PMCID: PMC2724800  PMID: 19680516
15.  Assessment of an intervention to train teaching hospital care providers in quality management 
Quality & safety in health care  2005;14(4):234-239.
Background: Successful implementation of continuous quality improvement (CQI) programs in hospitals remains rare in all countries, making it necessary to experiment with implementation methods while considering the cultural factors of resistance to change.
Objective: To assess the impact of an educational intervention on involvement of clinical department staff in the quality process.
Setting: Twelve voluntary clinical departments (six experimental and six controls) in a French 2000-bed university hospital comprising 40 clinical departments.
Intervention: Three day training seminar to a group of 12–20 staff members from each department.
Design: Quasi-experimental post-test only design study with control group conducted 12 months after the intervention with a questionnaire completed in a face-to-face interview.
Subjects: 98 trained staff and 100 untrained staff from the six experimental departments and 100 staff from the six control departments.
Principal measurements: Declared knowledge of the CQI methods and participation in quality management activities.
Results: 286 people (96%) were involved in the study. More of the trained staff knew the CQI methods (62.4%) than staff in the control departments (16.5%) (adjusted odds ratio (ORa) = 10.6 (95% CI 4.97 to 22.62)). More trained staff also participated in quality improvement work groups than control department staff (76.3% v 14.0%; ORa = 27.4 (95% CI 11.6 to 64.4)). In the experimental departments the untrained staff's knowledge of CQI methods and their participation in work groups did not differ from that of control department staff.
Conclusions: A continuing education intervention can involve care providers in CQI. Dissemination of knowledge from trained personnel to other staff members remains limited.
doi:10.1136/qshc.2004.011924
PMCID: PMC1744059  PMID: 16076785
16.  The Influence of Injection Rate on the Hypnotic Effect of Propofol during Anesthesia: A Randomized Trial 
PLoS Clinical Trials  2006;1(3):e17.
Objective:
Previous studies suggested that slow injection of propofol may increase the hypnotic effect during induction of anesthesia. The aim of the present study was therefore to investigate whether injection rate of propofol has an influence on its maximum effect.
Design:
Randomized, single-blind trial.
Setting:
This study has been carried out in the operating rooms of a university hospital. An anesthesiologist and a resident performed the study with the aid of changing nursing staff.
Participants:
We investigated 99 unpremedicated patients aged 18 to 60 years with American Society of Anesthesiologists (ASA) physical status 1–3.
Interventions:
Anesthesia was induced by intravenous injection of propofol (2 mg/kg). Propofol was manually injected in group 1 over a period of 5 s; in group 2 (120-s injection interval), and in group 3 (240-s injection interval), propofol was administered by an injection pump. After loss of consciousness, mask ventilation was performed with 100% oxygen. Bispectral index (BIS) was used to measure the hypnotic effect of propofol. After the decrease of BIS to the minimum value (i.e., maximum hypnotic effect) and the following increase of BIS to 60, the study period was finished and anesthesia was performed according to clinical criteria.
Outcome Measures:
We analyzed whether injection speed has an influence on the maximum hypnotic effect of a given dose of propofol (2 mg/kg).
Results:
BISmin marks the maximum electroencephalogram (EEG) effect of the propofol bolus as measured by the BIS. The lowest mean BISmin was measured in group 1 (28.7 ± 10.3). In group 2, BISmin was 33.0 (±13.9), and in group 3, BISmin was 36.4 (±11.0). There were no significant differences between group 2 and groups 1 or 3, but there were significant differences between groups 1 and 3. In group 1, BISmin was reached after 102.91 s (±44.20), in group 2 after 172.33 s (±29.76), and in group 3 after 274.21 s (±45.40). These differences were statistically significant for all comparisons. In summary, the lowest value for BISmin was achieved in the group with the fastest rate of propofol injection (group1, 5 s). The highest BISmin was obtained in the group with the slowest rate of injection (group 3, 240 s). The hemodynamic parameters were not significantly different among groups.
Conclusions:
The hypnotic peak effect of propofol is lower with extremely slow injection (240 s versus 5 s). For clinically usual injection rates (5 s and 120 s), there was no significant difference in propofol peak effect.
Editorial Commentary
Background: Propofol is an injectable compound that is commonly used to bring about anesthesia in adults and in children aged more than three years. The rate at which propofol is injected is thought to affect the total dose of the drug that's needed to achieve loss of consciousness and lowered blood pressure during anesthesia. Previous trials have looked at the effect of different injection rates on anesthesia (time taken to lose consciousness, and degree of consciousness). In this trial of 99 patients scheduled for elective surgery, the researchers studied the effect of three different propofol injection rates. Patients were randomized to receive propofol injected over 5 s, 120 s, or 240 s. In each group the total dose of propofol (per kilogram of a patient's bodyweight) was the same. The main measure used to assess anesthetic effect was the bispectral index. This is a method of translating information from an electroencephalogram (graph showing electrical activity in the brain) into a standard measurement that reflects the patient's level of consciousness. The researchers also recorded time to loss of consciousness, i.e., when patients stopped responding to commands, and took blood pressure measurements.
What this trial shows: The researchers found that anesthetic effect, as measured using the bispectral index, was greatest in the patients who had received the fastest injections as compared with those who had received slower injections. However, the difference was only significant when comparing the fastest injection (5 seconds) with the slowest (240 seconds). In addition, the time taken to achieve anesthesia (as measured using the bispectral index), and time to loss of consciousness (as indicated by no response to commands), were lowest in patients who had the fastest injections; these differences were also significant. The researchers did not find an effect of the different injection rates on maximum and minimum blood pressure during the trial.
Strengths and limitations: The trial recruited enough patients to properly assess whether patients receiving different injection rates would have different responses to anesthesia. A limitation, acknowledged by the authors, is that the bispectral index uses a commercial computer program to interpret electroencephalograms and to produce a number value for anesthetic effect. Some evidence suggests that the output of the computer program may not correlate precisely with level of consciousness, and as the algorithm is not public, any irregularities in the way it works cannot be discovered by researchers outside the company. It is also of note that the slowest injection rate used by the researchers, 240 seconds, is not normally used in clinical practice.
Contribution to the evidence: The results of this study support those from a few other small randomized trials that faster injections of propofol achieve a larger anesthetic effect, and more quickly. However, the effect of injection rate on blood pressure is less clear; this study does not show any differences in the effect of injection rate on blood pressure, but other randomized trials have found an association.
doi:10.1371/journal.pctr.0010017
PMCID: PMC1523225  PMID: 16878179
17.  Patient Safety in the Operating Room 
Seminars in Plastic Surgery  2006;20(4):214-218.
ABSTRACT
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during elective cosmetic surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementation of patient safety guidelines by the plastic surgeon is of increasing importance.
Key aspects of patient safety in the operating room include thoughtful patient positioning, ocular protection, proper handling of electrocautery, and airway management. If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain. In this article we discuss proper patient positioning with attention to protection against nerve palsy. Further, we discuss common patient positions on the operative table and highlight special concerns associated with each position. Other safety issues including prevention of ocular injury and proper management of electrocautery are discussed.
Responsibility of postoperative complications ultimately lies with the surgeon. Careful attention to patient safety guidelines is of paramount importance to surgeons, especially during elective cosmetic procedures. Attention to detail in patient positioning, eye protection, and bovie use can help avoid unnecessary perioperative complications and significantly improve the patient's cosmetic surgery experience.
doi:10.1055/s-2006-951578
PMCID: PMC2884786
Patient safety; operating room; patient positioning; ocular injury; electrosurgery; nerve injury
18.  Risk of latent TB infection in individuals employed in the healthcare sector in Germany: a multicentre prevalence study 
BMC Infectious Diseases  2010;10:107.
Background
Healthcare workers are still recognised as a high-risk group for latent TB infection (LTBI). Therefore, the screening of people employed in the healthcare sector for active and LTBI is fundamental to infection control programmes in German hospitals. It was the aim of the study to determine the prevalence and putative risk factors of LTBI.
Methods
We tested 2028 employees in the healthcare sector with the QuantiFERON-Gold In-tube (QFT-IT) test between December 2005 and May 2009, either in the course of contact tracing or in serial testing of TB high-risk groups following German OSH legislation.
Results
A positive IGRA was found in 9.9% of the healthcare workers (HCWs). Nurses and physicians showed similar prevalence rates (9.7% to 9.6%). Analysed by occupational group, the highest prevalence was found in administration staff and ancillary nursing staff (17.4% and 16.7%). None of the individuals in the trainee group showed a positive IGRA result. In the different workplaces the observed prevalence was 14.7% in administration, 12.0% in geriatric care, 14.2% in technicians (radiology, laboratory and pathology), 6.5% in admission ward staff and 8.3% in the staff of pulmonary/infectious disease wards. Putative risk factors for LTBI were age (>55 years: OR14.7, 95% CI 5.1-42.1), being foreign-born (OR 1.99, 95% CI 1.4-2.8), TB in the individual's own history (OR 4.96, 95% CI 1.99-12.3) and previous positive TST results (OR 3.5, 95% CI 2.4-4.98). We observed no statistically significant association with gender, BCG vaccination, workplace or profession.
Conclusion
The prevalence of LTBI in low-incidence countries depends on age. We found no positive IGRA results among trainees in the healthcare sector. Incidence studies are needed to assess the infection risk. Pre-employment screening might be helpful in this endeavour.
doi:10.1186/1471-2334-10-107
PMCID: PMC2877045  PMID: 20429957
19.  Improving on-time surgical starts in an operating room 
Canadian Journal of Surgery  2010;53(3):167-170.
Background
Operating rooms are expensive to run, and hospitals strive to be efficient. The purpose of this study was to evaluate an initiative to improve starting on time in the operating room in an academic pediatric hospital.
Methods
We used an 8-step approach to transforming an organization. A multidisciplinary team defined on-time starts, identified reasons for delays and instituted changes, including improving the same-day admission process, instituting a huddle of operating room staff each morning and providing feedback about on-time starts to staff.
Results
The most common reasons for delay were surgeon and anesthesiologist unavailability and lack of preparedness of patients. The percentage of operations that began on time, defined as the patient being in the room, increased from about 6% to 60% over a 9-month period.
Conclusion
A targeted, multifaceted and multidisciplinary approach can increase the percentage of operations that begin on time in a pediatric hospital.
PMCID: PMC2878988  PMID: 20507788
20.  Standard concentrations of high-alert drug infusions across paediatric acute care 
Paediatrics & Child Health  2008;13(5):371-376.
BACKGROUND
To reduce the risk of medication errors in paediatric patients, the Canadian Council on Health Services Accreditation endorsed the standardization and limiting of drug concentrations available within an organization.
METHODS
Standard concentrations (SCs) were implemented in the emergency department, operating room and paediatric intensive care unit at the Children’s Hospital of Eastern Ontario in Ottawa, Ontario. The change in practice involved addressing concerns raised during stakeholder consultations, developing a computer program, and educating and testing staff in the new method. The software for SC selection and infusion rate calculation featured redundant inputs, a ‘deviation’ column comparing the prescribed and infused doses, and a printout of patient information that also facilitated dose verification back-calculation.
RESULTS
The major barrier to acceptance of SCs was possible fluid overload in lower weight patients. Thus, infusions received by 48 successive infants in the paediatric intensive care unit were compared with theoretical SC infusions. Volumes were not significantly increased, and there was no trend toward proportionally larger volumes in lower weight patients. Medication error reporting was very low before implementation, and SC errors remained low; new online reporting led to higher reporting of other errors after implementation. A survey indicated excellent staff acceptance and beliefs that patient safety and continuity of care were improved.
INTERPRETATION
SCs were successfully instituted with computer support, in lieu of ‘smart pumps,’ across multiple critical care units in a paediatric institution. The initial program is being expanded to 40 continuous infusion drugs, plus paediatric advanced life support bolus medications.
PMCID: PMC2532888  PMID: 19412363
Critical care; High-alert medications; Intravenous; Medication safety; Paediatrics; Standard concentrations
21.  Improving Cardiac Surgical Care: A Work Systems Approach 
Applied ergonomics  2010;41(5):701-712.
Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.
doi:10.1016/j.apergo.2009.12.008
PMCID: PMC2879339  PMID: 20202623
Safety; Surgery; Error
22.  Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study 
PLoS ONE  2014;9(1):e86167.
Background
The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.
Methods
Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.
Results
Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.
Conclusion
Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.
doi:10.1371/journal.pone.0086167
PMCID: PMC3891872  PMID: 24454958
23.  SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study 
BMJ Open  2014;4(1):e004268.
Objectives
We aimed to examine staff members’ perceptions of communication within and between different professions, safety attitudes and psychological empowerment, prior to and after implementation of the communication tool Situation-Background-Assessment-Recommendation (SBAR) at an anaesthetic clinic. The aim was also to study whether there was any change in the proportion of incident reports caused by communication errors.
Design
A prospective intervention study with comparison group using preassessments and postassessments. Questionnaire data were collected from staff in an intervention (n=100) and a comparison group (n=69) at the anaesthetic clinic in two hospitals prior to (2011) and after (2012) implementation of SBAR. The proportion of incident reports due to communication errors was calculated during a 1-year period prior to and after implementation.
Setting
Anaesthetic clinics at two hospitals in Sweden.
Participants
All licensed practical nurses, registered nurses and physicians working in the operating theatres, intensive care units and postanaesthesia care units at anaesthetic clinics in two hospitals were invited to participate.
Intervention
Implementation of SBAR in an anaesthetic clinic.
Primary and secondary outcomes
The primary outcomes were staff members’ perception of communication within and between different professions, as well as their perceptions of safety attitudes. Secondary outcomes were psychological empowerment and incident reports due to error of communication.
Results
In the intervention group, there were statistically significant improvements in the factors ‘Between-group communication accuracy’ (p=0.039) and ‘Safety climate’ (p=0.011). The proportion of incident reports due to communication errors decreased significantly (p<0.0001) in the intervention group, from 31% to 11%.
Conclusions
Implementing the communication tool SBAR in anaesthetic clinics was associated with improvement in staff members’ perception of communication between professionals and their perception of the safety climate as well as with a decreased proportion of incident reports related to communication errors.
Trial registration
ISRCTN37251313.
doi:10.1136/bmjopen-2013-004268
PMCID: PMC3902348  PMID: 24448849
24.  Patients’ experience of important factors in the healthcare environment in oncology care 
Background and objective
The aim of this study was to describe what factors of the healthcare environment are perceived as being important to patients in oncology care.
Design
A qualitative design was adopted using focus group interviews.
Setting and participants
The sample was 11 patients with different cancer diagnoses in an oncology ward at a university hospital in west Sweden.
Results
Analysis of the patients’ perceptions of the environment indicated a complex entity comprising several aspects. These came together in a structure consisting of three main categories: safety, partnership with the staff, and physical space. The care environment is perceived as a complex entity, made up of several physical and psychosocial aspects, where the physical factors are subordinated by the psychosocial factors. It is clearly demonstrated that the patients’ primary desire was a psychosocial environment where they were seen as a unique person; the patients wanted opportunities for good encounters with staff, fellow patients, and family members, supported by a good physical environment; and the patients valued highly a place to withdraw and rest.
Conclusions
This study presents those attributes that are valued by cancer patients as crucial and important for the support of their well-being and functioning. The results show that physical aspects were subordinate to psychosocial factors, which emerged strongly as being the most important in a caring environment.
doi:10.3402/qhw.v8i0.20870
PMCID: PMC3737438  PMID: 23924604
Patients' experience; patient perspective; oncological care; physical and psychosocial factors; person-centred care
25.  Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events 
Korean Journal of Anesthesiology  2011;60(3):151-160.
Hemorrhage is the major cause of cardiac arrest developing in the operating room. Many human factors including surgical procedures, transfusion practices, blood supply, and anesthetic management are involved in the process that leads to hemorrhage developing into a critical situation. It is desirable for hospital transfusion committees to prepare hospital regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these regulations by simulated drills. If intraoperative hemorrhage seems to be critical, a state of emergency should immediately be declared to the operating room staff, the blood transfusion service staff, and blood bank staff in order to organize a systematic approach to the ongoing problem and keep all responsible staff working outside the operating room informed of events developing in the operating room. To rapidly deal with critical hemorrhage, not only cooperation between anesthesiologists and surgeons but also linkage of operating rooms with blood transfusion services and a blood bank are important. When time is short, cross-matching tests are omitted, and ABO-identical red blood cells are used. When supplies of ABO-identical red blood cells are not available, ABO-compatible, non-identical red blood cells are used. Because a systematic, not individual, approach is required to prevent and manage critical hemorrhage, whether a hospital can establish a procedure to deal with it or not depends on the overall capability of critical and crisis management of the hospital.
doi:10.4097/kjae.2011.60.3.151
PMCID: PMC3071477  PMID: 21490815
Crisis management; Hemorrhage; Risk management; Transfusion

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