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PubMed2004

[Critical incidents due to drug administration error in the operating room: an analysis of 4,291,925 anesthetics over a 4 year period].

BACKGROUND: Wrong drugs, overdose of drugs, and incorrect administration route remain unsolved problems in anesthetic practice. We determined the incidence and outcome of drug administration error in the operating room of Japanese Society of Anesthesiologists Certified Training Hospitals. METHODS: Data were obtained from annual surveys conducted by Japanese Society of Anesthesiologists between 1999 and 2002. There were 4,291,925 cases of anesthetic delivery for this analysis. RESULTS: Incidence of critical incidents due to drug administration error was 18.27/100,000 anesthetics. Cardiac arrest occurred in 2.21 patients per 100,000 anesthetics. Causes of these critical incidents were as follows: overdose or selection error involving non-anesthetic drugs, 42.1%; overdose of anesthetics, 28.7%; inadvertent high spinal anesthesia, 17.9%; local anesthetic intoxication, 6.4%; ampule or syringe swap, 4.3%; blood mismatch, 0.6%. Incidence of death following these incidents was 0.44/100,000. Causes of death were as follows: overdose or selection error involving non-anesthetic drugs, 47.4%; overdose of anesthetics, 26.3%; inadvertent high spinal anesthesia, 15.8%; local anesthetic intoxication, 5.3%. Ampule or syringe swap did not lead to any fatalities. Death following inadvertent high spinal anesthesia and local anesthetic intoxication was reported only in patients who had developed cardiac arrest. It should be noted that 88 percent of ampule or syringe swap occurred in patients with American Society of Anesthesiologists-Physical Status 1 or 2, who did not seem to require complex anesthetic management. CONCLUSIONS: We should increase awareness that drug administration is generally performed with limited objective monitoring, although "To error is human". Increased vigilance is required to avoid drug administration error in the operating room. Additional anesthesia resident education, adequate supervision, and improved organization are necessary. Bar-coding technology might be useful in preventing drug administration error.

Anesthetics↗

PubMed1984

[Pollution of operating rooms with volatile and gas anesthetics. Methods of prevention].

Gaseous anaesthetic pollution in operating theatres has been known since as far back as 1924. Following Vaisman and Cohen's epidemiology studies, health organizations have been involved in this professional concern. Halogenated vapours and nitrous oxide anaesthetic pollution have been accused of doubling the abortion rate and of moderately increasing the number of congenital abnormalities in the offsprings of anaesthetists. The liver and nervous system are also likely targets for anaesthetic pollution. Animal or cell culture experimental studies concerning pathological consequences of exposure to nitrous oxide or halogenated vapours give conflicting results and are not conclusive. The pollution rate is measured by chromatography and spectrophotometry. 25 ppm nitrous oxide and 2 ppm halothane are the upper limits allowed for air contamination. Total intravenous anaesthesia, closed circuits, draining away expired gases can prevent such pollution, but these techniques do have drawbacks. Pollution prevention is rather simple, moderately expensive and comforting for operating room staff.

Air Pollution↗

PubMed1994

Sleep patterns, shiftwork, and individual differences: a comparison of onshore and offshore control-room operators.

The sleep patterns of offshore control-room operators were compared with those of personnel carrying out similar work onshore, taking into account individual differences in age, number of years of shiftwork, and neuroticism. The dependent variables were self-reported sleep quality and duration for day-shift (D-S) and night-shift (N-S) work, and during leave periods (L-P). Offshore workers reported longer N-S sleep duration, and lower D-S sleep quality than those onshore, but the two groups did not differ in L-P measures. The effects of environmental differences (onshore versus offshore) on sleep patterns were more marked than those of the two different shift systems (weekly rotation and fast rotation) in operation onshore. Age was negatively related to both duration and quality of sleep; over and above age, number of years of shiftwork was negatively related to sleep duration. Neuroticism was also negatively related to sleep duration and, more strongly, to sleep quality. These findings are discussed in relation to the literature on shiftwork and sleep in general, and the characteristics of the offshore environment in particular.

Age Factors↗

PubMed2000

Infrared transmission of electronic information via LAN in the operating room.

Recent advances in technology have brought many kinds of monitoring devices into the operating room (OR). The information gathered by monitors can be channeled to the operating ward information system via a local area network (LAN). Connecting patients to monitors and monitors to the LAN, however, requires a large number of cables. This wiring is generally inconvenient and particularly troublesome if the layout of the OR is rearranged. From this point of view, wireless transmission seems ideally suited to clinical settings. Currently, two modes of wireless connectivity are available: radio-frequency (RF) waves or infrared (IR) waves. Some reports suggest that RF transmission is likely to cause electromagnetic interference (EMI) in medical devices such as cardiac pacemakers or infusion pumps. The risk of malfunctioning life-sustaining devices and the catastrophic consequences this would have on seriously ill patients rules out the use of RF. Here, we report an IR system using IR modems for LAN connectivity in the OR. In this study, we focused on the possible detrimental effects of EMI during wireless connectivity. In our trial, we found no evidence of EMI of IR modems with any of the medical devices we tested. Furthermore, IR modems showed similar performance to a wired system even in an electrically noisy environment. We conclude that IR wireless connectivity can be safely and effectively used in ORs.

Hospital Information Systems↗

PubMed2002

[Perioperative mortality and morbidity for the year 2000 in 532 Japanese Society of Anesthesiologists certified training hospitals: with a special reference to surgical sites--report of the Japan Society of Anesthesiologists Committee on Operating Room Safety].

Perioperative mortality and morbidity in Japan for the year 2000 were analyzed with special reference to operative regions. The total number of analyzed cases was 903,086. The percentages for each operative region were as follows, CRANIOTOMY 4.5%, THORACOTOMY 3.5%, HEART and GREAT-VESSELS 3.7%, THORACOTOMY with LAPAROTOMY 0.7%, LAPAROTOMY 30.4%, CESARIAN SECTION 3.3%, HEAD-NECK-ENT 14.7%, CHEST-ABDOMEN-PERINEUM 14.0%, SUPINE 3.6%, EXTREMITY including PERIPHERAL-VESSEL 17.2%, OTHERS 4.4%. The incidence of serious events, including cardiac arrest and severe hypotension and hypoxemia developing to cardiac arrest, was 26.74 per 10,000 anesthetics in all operative regions. The events were observed more frequently in HEART and GREAT-VESSELS 170.39, THORACOTOMY with LAPAROTOMY 85.84 and THORACOTOMY 63.63, and less frequently in CHEST-ABDOMEN-PERINEUM 10.49, CESARIAN SECTION 10.95 and EXTREMITY including PERIPHERAL-VESSEL 13.42. Regarding the prognosis of events, the cases with no sequelae were 63.4% in all operative regions. While there were fewer cases with no sequelae in CRANIOTOMY 49.0%, THORACOTOMY with LAPAROTOMY 43.4% and HEART and GREAT-VESSELS 44.4%, there were more cases in HEAD-NECK-ENT 86.9% and CHEST-ABDOMEN-PERINEUM 89.5%. The incidence of serious events totally attributable to anesthetic management was 5.24 per 10,000 anesthetics in all operative regions. The events were observed more frequently in THORACOTOMY 12.91 and SPINE 8.02, and less frequently in LAPAROTOMY except CESARIAN SECTION 4.11 and EXTREMITY including PERIPHERAL-VESSEL 4.65. The main cause of events in THORACOTOMY was inadequate airway management and in SPINE was inadequate airway management and the overdose or miss selection for drugs. Regarding the prognosis of events totally attributable to anesthetic management, the cases with no sequelae were 91.8% in all operative regions. There were fewer cases with no sequelae in HEART and GREAT-VESSELS 82.6%. The incidence of serious events totally attributable to anesthetic management was one fifth of all serious events in all operative regions. While the total deaths from 903,086 cases, including deaths in the operating room or within 7 postoperative days, were 641 cases (7.10 per 10,000 cases), the deaths totally attributable to anesthesia were 9 cases (0.10 per 10,000 cases).

Anesthesia↗

PubMed2003

Snap-shots of live theatre: the use of photography to research governance in operating room nursing.

The use of photography is an underreported method of research in the nursing literature. This paper explores its use in an ethnographic research project, the fieldwork of which was undertaken by the first author. The aim was to examine the governance of operating room nursing in the clinical setting and the theoretical orientation was the work of Michel Foucault. The focus of this paper is on how photography was used as a means of data generation. To establish some context we begin by drawing on writers from sociology and anthropology to provide an overview of the status of vision and visual research methods in contemporary social research. We then move to a brief discussion of the uses of photography in social research and the limitations imposed by ethical considerations of its use in clinical nursing settings. As well, the process and approach involved in this research project, and issues of analysis are discussed. Three 'snap-shots' of operating room nursing, taken by participants, are presented. Each is analysed in terms of its contributions to the research process as well as its substantive contribution to the theoretical framework and the research aims.

Anthropology, Cultural↗

PubMed1989

Thioethers, mutagens, and D-glucaric acid in urine of operating room personnel exposed to anesthetics.

Mutagenic hazards related to occupational exposure to nitrous oxide and enflurane was studied in the personnel of five operating rooms using a coupled environmental and biological monitoring approach. The environmental monitoring revealed air concentrations of the two anesthetics exceedings the TLVs by 10-15-fold. These values were correlated individually with the concentrations of the two anesthetics in the expired air of the exposed subjects. The biological monitoring was carried out by determining two parameters associated with mutagen exposure (urinary mutagenicity and thioethers) and a parameter associated with the enzymatic induction (D-glucaric acid) in the urine of exposed and unexposed subjects (N = 64 and N = 37, respectively). The results showed no difference in the two groups for urine mutagenicity and D-glucaric acid, but urine thioethers were significantly increased among highly exposed subjects.

Adult↗

PubMed2005

Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses.

This study describes how the potential sources of errors and error prevention in operating room (OR) teams are experienced by Finnish, American and British nurses. The data were collected by interviews and analysed using a qualitative content analysis. Results consisted of categories demanding teamwork practice, shared responsibility in teams and organized teamwork. The demanding practice category included fear of errors, turnover in teams, overtime work and emotional distress as potential factors leading to errors in OR teamwork. Shared responsibility emphasized how the familiar teams, safety control and formal documentation of errors prevented errors. At the organizational level, the prevention of errors required scheduling of work, good management, competency and a reasonable physical environment. In order to improve safety in OR teams, recognition should be given to the balance of error-making and learning from them. More effective ways in reporting incidents should be adopted and overall reporting systems should be developed in Finnish OR teams.

Adult↗

PubMed2000

Laparoscopic training on bench models: better and more cost effective than operating room experience?

BACKGROUND: Developing technical skill is essential to surgical training, but using the operating room for basic skill acquisition may be inefficient and expensive, especially for laparoscopic operations. This study determines if laparoscopic skills training using simulated tasks on a video-trainer improves the operative performance of surgery residents. STUDY DESIGN: Second- and third-year residents (n= 27) were prospectively randomized to receive formal laparoscopic skills training or to a control group. At baseline, residents had a validated global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by three evaluators who were blinded to the residents' randomization status. Residents were also tested on five standardized video-trainer tasks. The training group practiced the video-trainer tasks as a group for 30 minutes daily for 10 days. The control group received no formal training. All residents repeated the video-trainer test and underwent a second global assessment by the same three blinded evaluators at the end of the 1-month rotation. Within-person improvement was determined; improvement was adjusted for differences in baseline performance. RESULTS: Five residents were unable to participate because of scheduling problems; 9 residents in the training group and 13 residents in the control group completed the study. Baseline laparoscopic experience, video-trainer scores, and global assessments were not significantly different between the two groups. The training group on average practiced the video-trainer tasks 138 times (range 94 to 171 times); the control group did not practice any task. The trained group achieved significantly greater adjusted improvement in video-trainer scores (five of five tasks) and global assessments (four of eight criteria) over the course of the four-week curriculum, compared with controls. CONCLUSIONS: Intense training improves video-eye-hand skills and translates into improved operative performance for junior surgery residents. Surgical curricula should contain laparoscopic skills training.

Clinical Competence↗

PubMed1984

The operating room. A complex challenge for the nursing administrator.

The authors of this article show why nursing administrators need to be familiar with the complex operating room (OR) environment. They describe the management milieu in this high revenue-producing area of the hospital, and offer helpful suggestions for solving or at least ameliorating a number of problems that challenge OR directors and administrators.

Administrative Personnel↗

PubMed1990

Teamwork leads to better operating room management.

Because the diversity of staff members who work in hospital operating rooms (ORs) can cause conflicts and lead to inefficiencies, a team approach must be used to ensure better management of resources. Administrators, financial managers, and materials managers can join with OR personnel to improve scheduling, reduce time spent preparing and cleaning ORs, and better handle human resources. In the long run, reviewing OR demands and resources controls costs and improves the delivery of care.

Appointments and Schedules↗

PubMed1992

Resuscitative thoracotomy performed in the operating room.

The efficacy of resuscitative thoracotomy in the trauma patient has been questioned. Survival rates are variable, but a review of resuscitative thoracotomy in the emergency department of our institution documented an overall survival rate of only 1.8%. Higher survival rates may be anticipated in patients initially presenting with signs of life who can be transported directly to the operating room prior to the need for resuscitative thoracotomy. To test this hypothesis, the clinical course of all injured patients undergoing urgent or exigent thoracotomy in the operating room between July 1983 and June 1989 was reviewed. There were 34 patients undergoing exigent/resuscitative thoracotomy, 8 with penetrating injuries, 25 with blunt trauma to multiple systems, and 1 with isolated blunt chest trauma. Eight median sternotomies were performed and 26 left or bilateral thoracotomies. Twenty-six patients underwent concurrent exploratory celiotomy. The overall survival rate was 9% (3 of 34). The survival rate for patients with penetrating injuries was 37.5% (3 of 8) and 0% (0 of 26) for those with blunt trauma. Fifty-four patients underwent urgent/nonresuscitative thoracotomy with an overall survival rate of 74% (40 of 54). Combined group survival rates were 49% overall, 77% for patients with penetrating wounds, and 22% for patients with blunt trauma. These data underscore the futility of resuscitative thoracotomy in patients with blunt trauma who have deteriorated to the point of being in extremis. The relatively high salvage rates in patients with penetrating injuries support continued use of resuscitative thoracotomy when vital signs are lost, particularly if the injury is to the thorax. Variability in reported survival rates may be primarily due to the mix of patients with blunt trauma and penetrating injuries and disagreement as to what constitutes a resuscitative thoracotomy.

Adolescent↗

PubMedDate not supplied

Trace anesthetic vapors in hospital operating-room environments.

This study investigated concentrations of halothane anesthetic vapors in the operating rooms of two hospitals in the Ottawa, Ontario, Canada, area. Air samples, taken by active charcoal tubes and dosimeter badges, were analyzed by a gas chromatographic technique. Readings of 71 samples taken from hospital A and 65 samples from hospital B ranged from 1.0 to 29.4 parts per billion (ppb) for the active period and 0.1 to 3.8 ppb for the inactive period. All samples showed trace concentrations of halothane, but were well below the recommended maximal level.

Air↗

PubMed1993

A method of evaluating efficiency in the operating room.

A scientific four-step approach to evaluating efficiency in the operating room (OR) is described. These steps include identification of sequential work activities (SWAs) that are critical to the timely progression of surgical cases through the OR, identification of a time standard for completion of SWAs, direct observations of the amount of time required for completion of SWAs, and analysis of results. Two strategies to improve OR efficiency are described. Intergroup strategies require coordination of work among various specialty groups involved with the progress of cases through the OR. Interpersonal strategies necessitate coordination of work between two or more people within the same specialty group.

Anesthesiology↗

PubMed2003

Medical informatics--a catalyst for operating room transformation.

For many years, computers have supported complex clinical ancillary functions such as the laboratory, radiology, endoscopy, and others. Digital computers have been successfully incorporated into specialized clinical instruments to offer advanced digital devices such as fetal monitors, heart monitors, and imaging equipment. But these devices are often not fully integrated with clinical management and operational systems. Beyond ancillary department applications, the result of almost 30 years of trying to automate the clinical processes in healthcare is large investments in both computer systems and paper medical records that have resulted in paper-based, computer-assisted processes of care. This expensive combination of partial clinical automation and archaic paper-based support processes is a major obstacle to improvements in care delivery and management. The need to use software, informatics, and standards to help manage the operating room and perioperative processes of care is significant. The potential to reduce adverse events, cost of care, and to enhance the quality of care are real and worth attaining. This paper focuses on what medical informatics improvements are needed to support improvements in surgical care and to assist in the management of the highly complex operating room and perioperative care process, and proposes research priorities in these areas.

Humans↗

PubMed1980

[Infrared spectrometry and gas chromatography for determination of halothane in operation rooms (author's transl)].

Chronic halothane intoxication is a health hazard to anaesthetic personnel and requires permanent control of the degree of exposure. Two different methods are described: a continuous infrared spectrometric and an intermittent gas chromatographic determination of airborne halothane. An elaborate instruction for the measuring procedure is given; calibration techniques and detection limits are discussed. Data from operating rooms with different security equipment are listed. For determining the total burden gas chromatography is the method of choice, as the concentration range to be detected is rather low in general. In addition infrared spectrometric concentration monitoring gives valuable information about concentration peaks caused by typical handling in an operation room.

Air Pollutants↗

PubMed1993

Audit of intensive care unit admissions from the operating room.

An audit of 265 intensive care unit (ICU) admissions from the operating room was performed for the year 1991. In a quality assurance exercise we identified 34 unanticipated ICU admissions (UIAs) by a retrospective peer review of the medical charts. Of these UIAs, 16 were deemed predictable and seven preventable. Five of the seven potentially preventable UIAs were judged to have had inappropriate intravenous fluid management. This has prompted changes in our education programme. In an assessment of our resource management, we evaluated prospectively collected data on the Apache II scores on the day of admission, the incidence of ICU-specific interventions, length of stay in ICU, and outcomes. ICU-specific interventions were not initially required in 36% of admissions and these patients had a low risk (1.1%) of eventually requiring ICU-specific interventions. In comparison with patients requiring ICU-specific interventions, they had lower Apache II scores (10.2 vs 13.1), shorter ICU stays (medians of one vs two days), lower ICU mortality (0 vs 8.2%), P < 0.05, but hospital mortality was not different (7.4 vs 15.3%). This audit has prompted reorganisation of our intensive care services, so that patients not requiring ICU-specific interventions will be managed in an intermediate care area with nurse:patient ratios of 1:3 or 4, in comparison with 1:1 or 2 ratios in the intensive care area.

Ambulatory Surgical Procedures↗

PubMed2001

Novel, compact, intraoperative magnetic resonance imaging-guided system for conventional neurosurgical operating rooms.

OBJECTIVE: Preliminary clinical experience with a novel, compact, intraoperative magnetic resonance imaging (MRI)-guided system that can be used in an ordinary operating room is presented. DESCRIPTION OF INSTRUMENTATION: The system features an MRI scanner integrated with an optical and MRI tracking system. Scanning and navigation, which are operated by the surgeon, are controlled by an in-room computer workstation with a liquid crystal display screen. The scanner includes a 0.12-T permanent magnet with a 25-cm vertical gap, accommodating the patient's head. The field of view is 11 x 16 cm, encompassing the surgical area of interest. The magnet is mounted on a transportable gantry that can be positioned under the surgical table when not in use for scanning, thus rendering the surgical environment unmodified and allowing the use of standard instruments. The features of the integrated navigation system allow flap planning and intraoperative tracking based on updated images acquired during surgery. OPERATIVE TECHNIQUE: Twenty patients with brain tumors were surgically treated using craniotomy or trans-sphenoidal approaches. One patient underwent conscious craniotomy with cortical mapping, and two underwent electrocorticography. EXPERIENCE AND RESULTS: Planning was accurate. Resection control images were obtained for all patients during surgery, with precise localization of residual tumor tissue. There were no surgical complications related to the use of the system. CONCLUSION: This intraoperative MRI system can function in a normal operating room modified only to eliminate radiofrequency interference. The operative environment is normal, and standard instruments can be used. The scanning and navigation capabilities of the system eliminate the inaccuracies that may result from brain shift. This novel type of intraoperative MRI system represents another step toward the introduction of the modality as a standard method in neurosurgery.

Adolescent↗