McMillan Matthew W, Lehnus Kristina S
Queen's Veterinary School Hospital, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK.
Queen's Veterinary School Hospital, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK.
Vet Anaesth Analg. 2018 Jan;45(1):3-12. doi: 10.1016/j.vaa.2017.06.007. Epub 2017 Aug 5.
To identify factors contributing to the development of anaesthetic safety incidents.
Prospective, descriptive, voluntary reporting audit of safety incidents with subsequent systems analysis.
All animals anaesthetized in a multispecies veterinary teaching hospital from November 2014 to October 2016.
Peri-anaesthetic incidents that risked or caused unnecessary harm to an animal were reported by anaesthetists alongside animal morbidity and mortality data. A modified systems analysis framework was used to identify contributing factors from the following categories: Animal and Owner, Task and Technology, Individual, Team, Work Environmental, and Organizational and Management. The outcome was graded using a simple descriptive scale. Data were analysed using Pearson's Chi-Square test for association and univariable and multivariable logistic regression analysis.
Totally, 3379 anaesthetics were performed during the audit period. Of these, 174 incident reports were analysed, 163 of which impacted safe veterinary care and 26 incidents were considered to have had major or catastrophic outcomes. Incident outcome was believed to have been limited by anaesthetist intervention in 104 (63.8%) cases. Various factors were identified as: Individual in 123 (70.7%), Team in 108 (62.1%), Organizational and Management in 94 (54.0%), Task and Technology in 80 (46.0%), Work Environmental in 53 (30.5%) and Animal and Owner in 36 (20.7%) incidents. Individual factors were rarely seen in isolation. Significant associations were identified between Experience and Supervision, X (1, n=174)=54177, p=0.001, Failure to follow a standard operating procedure and Task Management, X (2, n=174)=11318, p=0.001, and Staffing and Poor Scheduling, X (1, n=174)=36742, p=0.001. Animal Condition [odds ratio (OR)=16210, 95% confidence interval (CI)=5573-47147)] and anaesthetist Decision Making (OR=3437, 95% CI=1184-9974) were risk factors for catastrophic and major outcomes.
Individual factors contribute to many safety incidents but tend to occur concurrently with other factors. Anaesthetist intervention limits the consequences of incidents for most animals.
确定导致麻醉安全事件发生的因素。
对安全事件进行前瞻性、描述性、自愿报告审计，并随后进行系统分析。
2014年11月至2016年10月在一家多物种兽医教学医院接受麻醉的所有动物。
麻醉师报告围麻醉期有风险或对动物造成不必要伤害的事件，以及动物发病和死亡数据。使用经过修改的系统分析框架，从以下类别中确定促成因素：动物和主人、任务和技术、个人、团队、工作环境以及组织与管理。结果使用简单的描述性量表进行分级。使用Pearson卡方检验进行关联性分析以及单变量和多变量逻辑回归分析。
在审计期间共进行了3379例麻醉。其中，分析了174份事件报告，其中163份影响了安全的兽医护理，26起事件被认为产生了重大或灾难性后果。据信，在104例（63.8%）病例中，麻醉师的干预限制了事件结果。确定了各种因素如下：个人因素占123例（70.7%），团队因素占108例（62.1%），组织与管理因素占94例（54.0%），任务和技术因素占80例（46.0%），工作环境因素占53例（30.5%），动物和主人因素占36例（20.7%）。个人因素很少单独出现。经验与监督之间存在显著关联，X（1，n = 174）= 54177，p = 0.001；未遵循标准操作程序与任务管理之间存在显著关联，X（2，n = 174）= 11318，p = 0.001；人员配备与排班不当之间存在显著关联，X（1，n = 174）= 36742，p = 0.001。动物状况[比值比（OR）= 16210，95%置信区间（CI）= 5573 - 47147]和麻醉师的决策（OR = 3437，95% CI = 1184 - 9974）是导致灾难性和重大后果的风险因素。
个人因素导致许多安全事件，但往往与其他因素同时发生。麻醉师的干预限制了大多数动物事件的后果。
