From the Veterans Health Administration (VHA) National Center for Patient Safety (NCPS), White River Junction, Vermont.
National Anesthesia Service, US Department of Veterans Affairs, Washington, DC.
Anesth Analg. 2018 Feb;126(2):471-477. doi: 10.1213/ANE.0000000000002149.
Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions.
RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics.
During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes.
This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.
麻醉师一直是患者安全领域的先驱。尽管付出了巨大努力，但麻醉相关差错仍时有发生，导致并发症、损伤甚至死亡。退伍军人健康管理局（VHA）国家患者安全中心利用根本原因分析（RCA）来研究为什么会发生与系统相关的不良事件，以及如何预防未来类似的事件。本研究描述了退伍军人健康管理局医院报告的麻醉不良事件类型及其根本原因和预防措施。
对 2012 年 5 月 30 日至 2015 年 5 月 1 日期间退伍军人健康管理局医院提交的 RCA 报告进行了回顾，以确定根本原因、患者结局的严重程度和行动。这些要素经共识编码后，采用描述性统计进行分析。
在研究期间，共提交了 3228 份 RCA，其中 292 份涉及麻醉提供者。其中 36 份专门针对麻醉护理。我们审查了这 36 份专门针对麻醉护理的不良事件 RCA 报告。事件类型包括用药错误（28%，10 例）、区域阻滞（14%，5 例）、气道管理（14%，5 例）、皮肤完整性或体位（11%，4 例）、其他（11%，4 例）、同意问题（8%，3 例）、设备（8%，3 例）和静脉通路和麻醉意识（3%，各 1 例）。在报告的 36 例麻醉事件中，有 5 例（14%）被确定为灾难性，10 例（28%）为重大，12 例（34%）为中度，9 例（26%）为轻度。大多数根本原因表明需要改进流程的标准化。
该分析表明，需要在全系统实施基于人为因素工程的方法，以进一步消除与麻醉相关的不良事件。此类行动包括标准化流程、强制功能、将类似外观的药物分开存放、限制高危药物强度的库存、对药物进行条形码处理、使用清单等认知辅助工具，以及高保真模拟。
