Risk management for healthcare organizations

It is believed that more than 70% of errors in a medical organization can be prevented, in particular, by using risk management methods and implementing risk management tools in the practice of their activities. To this end, the authors conducted a study based on data from the analysis of scientific papers and regulatory documents regulating quality management and risk management in healthcare. The study summarizes the main approaches to implementing risk management methods in healthcare and suggests an algorithm for analyzing the types and consequences of potential failures in healthcare (HFMEA). As the analyzed process, the process of performing doctors appointments by medical nurses for drug therapy was chosen, which refers to the main medical events, and drug error is a serious problem in drug therapy. The results of the study revealed possible risks associated with each step. The study is appropriate due to the fact that many healthcare institutions are currently implementing a quality management system to improve their processes.

Cardiac Arrest and Complications after Spinal Anesthesia: The Perioperative and Anesthetic Adverse Event in Thailand (PAAd Thai) Incident Report Study

Background: Spinal anesthesia is one of most common anesthetic techniques in Thailand. The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study was a multicentered project among 22 hospitals across the country to investigate the incidence of anesthesia related complications. Objective: To study the incidences of cardiac arrest and complication after spinal anesthesia including the contributing factors and suggested corrective strategies. Materials and Methods: This prospective descriptive study of the incident reports that occurred regarding spinal anesthesia collected from 22 participating hospital in the data collection between January and December of 2015 was completed. Three senior anesthesiologists reviewed the data and descriptive statistics were used. Results: Among 62,120 spinal anesthesia, there were 127 incidents (5.8%) among 2,206 incident reports related to anesthesia. There were seven cases of intraoperative cardiac arrest with an incidence of 1.13:10,000 spinal anesthesia (95% CI 0.55 to 2.33). Other complications were bradycardia with less than 40 beats per minute (50.4%), anaphylaxis or anaphylactoid reaction or drug allergy (14.2%), drug error (8.4%), coma or CVA or convulsion (3.9%), and suspected pulmonary embolism (3.9%). Adverse events occurred frequently with specialties or surgeries of orthopedics (44.1%), cesarean delivery (17.3%), urosurgery (17.3%), general surgery (14.2%), and gynecological surgery (4.7%), respectively. Conclusion: Contributing factors were inexperience, inappropriate decision making, haste, and inappropriate pre-anesthetic evaluation or preparation while factors minimizing incidents were vigilance, having experience, and experienced assistants. Suggested corrective strategies were quality assurance activity, guidelines especially monitoring, improvement of supervision, and additional training. Keywords: Spinal anesthesia, Adverse events, Incidents, Complications, Neuraxial anesthesia, Cardiac arrest

Drug Error beyond the Hospital and Role of Pharmacists in drug Safety Process

Medication related error is one of the most common error prevailing in this time. Medication error can be defined as a ‘failure in the treatment process that leads to or has potential to lead to harm to the patient. Medication error can occur from the process of ordering to the administration to the patient. Among the healthcare professionals; a pharmacist can be responsible in identification of contributing factors and reducing its occurrence. Great efforts are needed in this area, due to diversity in the types of errors, the relationship between the provider and the patient, information transfer, optimization of e-prescribing systems, the lack of adequate training in analyzing the collected data and poor practical strategies for maintaining accurate drug lists in electronic medical records. Recently healthcare professionals have started becoming aware about the risks of patients’ medication exposure. After all, still the area of medication safety beyond the hospital setting needs community pharmacy intervention to avoid malpractice claims and misled decisions in solving medication safety-related problems in the outpatient setting. Approaches like medication reviews and reconciliation, monitoring drug therapy, reporting error will help in identify and prompt the detection of errors, open productive discussions, quality control checks, and effective system-based decisions like performing risk assessment subsequently reduces the harm and risks before patient is exposed to any form of drug error.

Paediatric postoperative analgesia prescribing report card: “could do better”

Background: A key element of paediatric pain management is prescribing and dispensing analgesia. This process differs in children, putting them at greater risk of drug error. Methods: This study was a retrospective postoperative analgesia prescription chart review of children who had orthopaedic surgery in a tertiary hospital in Durban, South Africa. Patient records of 202 children, aged 6 months to 12 years, with 232 theatre visits were reviewed. Prescription charts were inspected for patient characteristics, evidence of good prescribing practice and data regarding the prescribing and administration of analgesia. Results: Of the 257 analysed charts 254 (99%) had paracetamol, 208 (81%) had an opioid and 49 (19%) had a nonsteroidal antiinflammatory drug (NSAID) prescribed. Underdosing was evident in all groups of analgesics prescribed. Opioids were more often prescribed with a pro-re-nata caveat and were the least correctly dispensed. There were no prescription charts in which all the requirements for good prescribing practice were complete. Conclusions: This study demonstrates a high rate of paediatric drug error in both the prescribing and dispensing of analgesia. Potential under-utilisation of NSAIDs in this orthopaedic population is also noted. Lack of knowledge or confidence needed by clinicians to adhere to principles of paediatric dosing and multimodal analgesia may be contributing factors. Issues pertaining to paediatric analgesia prescribing and dispensing are highlighted and should be targeted by institution and population specific interventions.

Tips for the SJT

1. Put yourself in the position of a new FY1 doctor when answering each question. But remember that they are asking what you should do, not what you would do. 2. You should be a paragon of virtue when answering all questions. Remember always that you are unfailingly honest, respectful, open, and fair to colleagues, patients, and relatives alike. It is difficult to imagine scenarios with answers that would require you to be otherwise. 3. If a question involves patient safety (e.g. critically unwell patient, drug error, etc.), your priority must always be making the patient safe. 4. The well- being of your patient is your first priority. Other considerations (e.g. relatives, targets, fear of being told off, going home on time) are always secondary. 5. ‘Seeking senior advice’ and ‘gathering information’ are difficult to criticize and tend to be safe options. Similarly, it is rarely incorrect to document events or complete a formal incident form. 6. Remember your limitations. As an FY1 doctor, you should not usually break bad news, consent patients for operations, administer cytotoxic or anaesthetic drugs, or manage critically ill patients without support. ‘Call a senior’ is the correct answer in these cases. 7. Understand basic concepts of medical law, e.g. when confidentiality can be breached, determining incapacity, consent in children, the doctrine of double effect, and detention under the Mental Health Act. You do not need to know specifics (e.g. sections of Acts), but a practical understanding will guide some answers. 8. As an FY1 doctor, your Clinical Supervisor is usually a consultant for whom you work during a particular rotation. They are an appropriate source of support for clinical development and problems within the team. Your Educational Supervisor is akin to a Personal Tutor, i.e. responsible for your overall welfare and development throughout the year. They can advise on pastoral issues, professional development, and difficulties with your Clinical Supervisor. 9. Try to complete all questions within the given time frame as random guesses may be identified by the scoring software and awarded zero.