Department of Anesthesiology, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, New York, NY 10029-6574, USA.
Anesth Analg. 2011 Jul;113(1):84-8. doi: 10.1213/ANE.0b013e318219645e. Epub 2011 Apr 5.
Anesthesiologists accomplish many tasks rapidly during induction of an anesthetic. Key preparation for induction is needed to maximize patient safety. Given the intense environment of the operating room, preparatory steps may be missed either unintentionally or possibly even intentionally to save time. We conducted this study to determine the incidence of missed steps in the operating room immediately before induction.
In this study, 200 surgical procedures were randomly checked for missed steps before induction of anesthesia using a "Revised Preanesthetic Set-Up." Additionally, multiple other operating room/case variables were recorded to determine whether there was correlation between the missed steps and certain variables such as room case load and regional versus general anesthesia.
Twenty-three missed steps were discovered. Manual resuscitation device availability and a working suction set-up were the most frequently missed steps. A higher percentage of missed steps was found in cases in which regional was the planned anesthesia technique, in rooms with higher case loads (≥5 cases scheduled), and in rooms that attending anesthesiologists completed the set-up.
Missed steps do occur at a significant and measurable rate. Measures need to be taken to decrease the number of missed steps to improve patient safety.
麻醉师在进行麻醉诱导时需要快速完成多项任务。为了最大限度地提高患者安全性，需要对诱导前的准备工作进行充分准备。由于手术室环境紧张，准备步骤可能会因疏忽或可能故意节省时间而被遗漏。我们进行这项研究是为了确定麻醉诱导前手术室中遗漏步骤的发生率。
在这项研究中，使用“修订后的麻醉前设置”随机检查了 200 例手术程序在麻醉诱导前遗漏的步骤。此外，还记录了其他多个手术室/案例变量，以确定遗漏步骤与某些变量（如房间病例量和局部麻醉与全身麻醉）之间是否存在相关性。
发现了 23 个遗漏步骤。手动复苏设备的可用性和正常运行的抽吸设备是最常被遗漏的步骤。在计划采用局部麻醉技术的病例、病例量较高（≥5 例预约）的房间以及由主治麻醉师完成设置的房间中，发现遗漏步骤的比例更高。
遗漏步骤确实以显著且可衡量的速度发生。需要采取措施减少遗漏步骤的数量，以提高患者安全性。
