How do we know that we are doing a good job - Can we measure the quality of our work?

Best Practice and Research: Clinical Anaesthesiology

Volumn 25, Issue 2, 2011, Pages 109-122

  Gisvold, Sven Erik ^a   Fasting, Sigurd ^a  

^a TRONDHEIM UNIVERSITY HOSPITAL   (Norway)

Author keywords

adverse events; anaesthesia; outcome; quality indicators; quality measurements; statistical process control; surrogate outcome

Indexed keywords

ANESTHESIA; ANESTHESIOLOGY; CULTURAL ANTHROPOLOGY; DOCTOR PATIENT RELATION; HOSPITAL DEPARTMENT; HUMAN; INTERPERSONAL COMMUNICATION; MORBIDITY; MORTALITY; OUTCOME ASSESSMENT; PRIORITY JOURNAL; PROCESS CONTROL; QUALITY CONTROL; REVIEW; SKILL; TEAMWORK; TRUST; VALIDITY; WORK;

ANESTHESIOLOGY; HUMANS; PREOPERATIVE CARE; QUALITY INDICATORS, HEALTH CARE;

EID: 79955864141     PISSN: 15216896     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.bpa.2011.02.010     Document Type: Review

References (83)

1. Vincent C, Moorthy K, Sarker SK et al. Systems approaches to surgical quality and safety. From concept to measurement. Annals of Surgery 2004; 239: 475-482.
2. Vincent C. Incident reporting and patient safety. Emphasis is needed on measurement and safety improvement programs. British Medical Journal 2007; 334: 51.
3. Porter ME. What is value in health care? The New England Journal of Medicine 2010; 363: 2477-2481.
4. Lee TH. Putting the value framework to work. The New England Journal of Medicine 2010; 363: 2481-2483.
5. Gaba DM. Anaesthesiology as a model for patent safety in health care. British Medical Journal 2000; 320: 785-788.
6. Cooper JB & Gaba DM. No myth: anesthesia is a model for addressing patient safety. Anesthesiology 2002; 97: 1335-1337. (Pubitemid 35417429)
7. Flin R, Patey R, Glavin RJ et al. Anaesthetists' non-technical skills. British Journal of Anaesthesia 2010; 105: 38-44.
8. Glavin RJ. Excellence in anesthesiology. The role of nontechnical skills. Anesthesiology 2009; 110: 201-203.
9. Koetsier E, Boer C & Loer SA. Complaints and incident reports related to anaestesia service are foremost attributed to nontechnical skills. European Journal of Anaesthesiology 2011; 28: 29-33.
10. Helmreich RL, Merritt AC & Wilhelm JA. The evolution of crew resource management training in commercial aviation. International Journal of Aviation Psychology 1999; 9: 19-32.
11. Gaba DM. Out of this nettle, danger, we pluck this flower, safety: healthcare vs aviation and other high-hazard industries. Simulation in Healthcare 2007; 2: 213-217.
12. Lingard L, Espin S, Whyte S et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Quality & Safety in Health Care 2004; 13: 330-334. (Pubitemid 39389393)
13. Davies J. Team communication in the operating room. Acta Anaesthesiologica Scandinavica 2005; 49: 898-901.
14. Berwick D. Continuous improvement as an ideal in health care. The New England Journal of Medicine 1989; 320(1): 53-56.
15. Melody M & Clark G. Walking - planning rounds. The American Journal of Nursing 1967; 67: 771-773.
16. Coulter A. Paternalism or partnership? Patients have grown up and there is no going back. British Medical Journal 1999; 319: 719-720.
17. Lemmens LC, van Klei WA, Klazinga NS et al. The effect of national guidelines on the implementation of outpatient properative evaluation clinics in Dutch Hospitals. European Journal of Anaesthesiology 2006; 23: 962-970. (Pubitemid 44622951)
18. Schiff JJ, Frankenhauser S, Pritsch M et al. %The anaesthesia preoperative evaluation clinic (APEC): a prospective randomized controlled trial assessing the impact on consultation time, direct cost, patient education and satisfaction with anaesthesia care. Minerva Anestesiologica 2010; 76: 491-499.
19. Edward GM, de Haes JC, Oort FJ et al. Setting priorities for improving the properative assessment clinic: the patients and the professionals' perspective. British Journal of Anaesthesia 2008; 100: 322-326. (Pubitemid 351773644)
20. Vincent C, Toung M & Philips A. Why do people sue doctors? a study of patients and relatives taking legal action. Lancet 1994; 343: 1609-1613. (Pubitemid 24194811)
21. Davies JM. Disclosure. Acta Anaesthesiologica Scandinavica 2005; 49: 725-727.
22. Manser T & Staender S. Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure. Acta Anaesthesiologica Scandinavica 2005; 49: 728-734. (Pubitemid 40941883)
23. Dudzinski DM, Hebert PC, Foglia MB et al. The disclosure dilemma-large scale adverse events. The New England Journal of Medicine 2010; 363: 978-986.
24. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal 2000; 320: 726-727.
25. Aasland OG & Førde R. The impact of feeling responsible for serious adverse events. Quality & Safety in Health Care 2005; 14: 13-17.
26. Waterman AD, Garbutt J, Hazel E et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety 2007; 33: 5-14.
27. Scott SD, Hirschinger LE, Kox KR et al. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Quality & Safety in Health Care 2009; 18: 325-330.
28. Fasting S & Gisvold SE. Data recording of problems during anaesthesia: presentation of a well functioning and simple system. Acta Anaesthesiologica Scandinavica 1996; 40: 1173-1183.
29. Fasting S & Gisvold SE. Serious intraoperative problems. A five year review of 83844 anaesthetics. Canadian Journal of Anaesthesia 2002; 49: 545-553.
30. Mellin-Olsen J, Fasting S & Gisvold SE. Routine preoperative gastric emptyiong is seldom indicated. A study of 85594 anaesthetics with special focus on aspiration pneumonia. Acta Anaesthesiologica Scandinavica 1996; 40: 1184-1188.
31. Fasting S & Gisvold SE. Equipment problems during anaesthesia - are they a quality problem? British Journal of Anaesthesia 2002; 89: 825-831.
32. Fasting S & Gisvold SE. Adverse drug errors in anaesthesia and the impact of coloured syringe labels. Canadian Journal of Anaesthesia 2000; 47: 1060-1067. (Pubitemid 34257257)
33. Orkin FK. Practice standards: the midas touch or the emperor's new clothes? Anesthesiology 1989; 70: 567-571.
34. Lagasse RS. Indicators of anestesia quality and safety. Current Opinion in Anaesthesiology 2002; 15: 239-243.
35. Gravenstein JS. The burden of progress. A fable. Anesthesia & Analgesia 1991; 72: 262-270.
36. Keats AS. Anesthesia mortality in perspective. Anesthesia & Analgesia 1990; 71: 113-119.
37. Orkin FK, Cohen MM & Duncan PG. The quest for meaningful outcomes. Anesthesiology 1993; 78: 417-422. (Pubitemid 23090474)
38. Arbous MS, Grobbee DE, van Kleef JW et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia 2001; 56: 1141-1153. (Pubitemid 33103864)
39. Lienhart A, Auroy Y, Pequignot F et al. Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105: 1087-1097. (Pubitemid 44808572)
40. Kawashima Y, Takahashi S, Suzuki M et al. Anaesthesia related mortality and morbidity over a 5 year period in 2,363,038 patients in Japan. Acta Anaesthesiologica Scandinavica 2003; 47: 809-817.
41. Li G, Warner M, Lang BH et al. Epidemiology of anesthesia related mortality in the United states, 1999-2005. Anesthesiology 2009; 110: 759-765.
42. Cooper JB, Newbower RS & Long CD. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49: 399-406. (Pubitemid 9077572)
43. Epstein RM. Morbidity and mortality from anesthesia. Anesthesiology 1978; 49: 388-389.
44. Runciman WB, Sellen A, Webb RK et al. The Australian incident monitoring study. Errors, incidents and accidents in anaesthesia practice. Anaesthesia & Intensive Care 1993; 21: 506-519.
45. Cooper JB, Cullen DJ & Nemeskal R. Effects of information feedback and pulse oximetry on the incidence of anesthesia complications. Anesthesiology 1987; 67: 686-694.
46. Cohen MM, Duncan PG & Pope WDB. The Canadian four centre study on anesthetic outcomes: II. Can outcomes be used to assess the quality of anaesthesia care? Canadian Journal of Anaesthesia 1992; 39: 430-439.
47. Bothner U, Georgieff M & Schwilk B. Building a large scale perioperative anaesthesia outcome-tracking database: methodology, implementation, and experiences from one provider within the German quality project. British Journal of Anaesthesia 2000; 85: 271-280. (Pubitemid 30601620)
48. Choy CY. Critical Incident monitoring in anaesthesia. Current Opinion in Anaesthesiology 2008; 21: 183-186.
49. Merry AF. Safety in anaesthesia: reproting incidents and learning from them. Anaesthesia 2008; 63: 337-339. (Pubitemid 351365054)
50. Mahajan RP. Critical incident reporting and learning. British Journal of Anaesthesia 2010; 105: 69-75.
51. Beyer K, Taffe P, Halfon P, Pittet V, Pichard S & Haller G. Burnand B. (and the ADS study group). Hypertension and intraoperative incidents: a multicentre study of 125,000 surgical procedures in Swiss hospitals. Anaesthesia 2009; 64: 494-502.
52. Taffe P, Sicard N, Pittet V et al. The occurrence of intraoperaative hypotension varies between hospitals: observational analysis of more than 147,000 anaesthetics. Acta Anaesthesiologica Scandinavica 2009; 53: 995-1005.
53. Lundstrøm LH, Møller AM, Rosenstock C et al. A documented previous tracheal intuibation as aprognostic test for a subsequent difficult tracheal intubation. Anaesthesia 2009; 64: 1081-1088.
54. Hardman JG, Moppett IK & Mahajan RP. Validity, credibility, and applicability: the rise and rise of the surrogate. (editorial). British Journal of Anaesthesia 2008; 101: 595-596.
55. Haller G, Stoelwinder J, Myles PS et al. Quality and safety indicators in anesthesia. A systematic review. Anesthesiology 2009; 110: 1158-1175.
56. Marang van-de Mheen PJ, van Hanegem N & Kievit J. Effectiveness of routine repåorting to identify minor and serious adverse outcomes in surgical patients. Quality & Safety in Health Care 2005; 14: 378-382.
57. de Vries EN, Prins HA, Crolla RMPH et al. Effect of a comprehensive surgical safety system on patient outcomes. The New England Journal of Medicine 2010; 363: 1928-1937.
58. van Beuzekom M, Boer F, Akerboom S et al. Patient safety: latent risk factors. British Journal of Anaesthesia 2010; 105: 52-59.
59. McNicol L & Mackay P. Anaesthesia related morbidity in Victoria: a report from 1990 to 2005. Anaesthesia & Intensive Care 2010; 38: 837-848.
60. Haynes AB, Weiser TG, Berry WR et al. Safe surgery saves lives study group. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine 2009; 360: 491-499.
61. Birkmeyer JD. Strategies for improving surgical quality - checklists and beyond. (Editorial). The New England Journal of Medicine 2010; 363: 1963-1965.
62. Møller JT, Johannesen NW, Espersen K et al. Randomized evaluation of pulse oximetry in 20,802 patients: II perioperative events and postoperative complications. Anestehesiology 1993; 78: 445-453. (Pubitemid 23090478)
63. Orser BA. Medication safety in anaesthetic practice: first do no harm (editorial). Canadian Journal of Anaesthesia 2000; 47: 1051-1054.
64. Runciman WB, Roughead EE, Semple SJ et al. Adverse drug events and medication errors in Australia. The International Journal for Quality in Health Care 2003; 15(Suppl. 1): 49-59.
65. Webster CS, Merry AF, Larsson L et al. The frequency and nature of drug administration errors during anaesthesia. Anaesthesia & Intensive Care 2001; 29: 494-500. (Pubitemid 32970453)
66. Wheeler SJ & Wheeler DW. Medication errors in anaesthesia and critical care. Anaesthesia 2005; 60: 257-273. (Pubitemid 40310207)
67. Nel L & Eren E. Perioperative anaphylaxis. British Journal of Clinical Pharmacology 2011 Jan 14.
68. Dewachetr P, Mouton Faivre C & Emala CW. Anaphylaxis and anesthesia: controversies and new insights. Anaesthesiology 2009; 111: 1141-1150.
69. Kroigaard M, Garvey LH, Gillberg L et al. Scandinavian clinical practice guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia. Acta Anaesthesiologica Scandinavica 2007; 51: 655-670. (Pubitemid 46918542)
70. Johansson SG, Florvaag E, Oman H et al. National pholcodine consumption and prevalence of IgE-sensitization: a multicentre study. Allergy 2010; 65: 498-502.
71. Fasting S & Gisvold SE. Statistical process control methods allow the analysis and improvement of anaesthesia care. Canadian Journal of Anaesthesia 2003; 50: 767-774.
72. Auroy Y, Benhamou D, Bargues L et al. Major complications of regional anasthesia in France: the SOS regional anasthesia hotline service. Anesthesiology 2002; 97: 1274-1280. (Pubitemid 35265584)
73. Compere V, Rey N, Baert O et al. Major complications after 400 continuous popliteal sciatic nerve blocks for postoperative analgesia. Acta Anaesthesiologica Scandinavica 2009; 53: 339-345.
74. Breivik H. Neurological complications in association with spinal and epidural analgesia - again. Acta Anaesthesiologica Scandinavica 1998; 42: 609-613. (Pubitemid 28298630)
75. Moen V, Dahlgren N & Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-99. Anesthesiology 2004; 101: 950-959.
76. Tiret L, Desmonts JM, Hatton F et al. Complications associated with anaesthesia-a prospective study in France. Canadian Journal of Anaesthesia 1986; 37: 336-344. (Pubitemid 16070618)
77. Duclos A & Voirin N. The p-control chart: a tool for care improvement. The International Journal for Quality in Health Care 2010; 22: 402-407.
78. Lagasse RS, Steinberg ES, Katz RI et al. Defining quality of perioperative care by statistical process control of adverse outcomes. Anesthesiology 1995; 82: 1181-1188.
79. Benneyan JC. Statistical quality control methods in infection control and hospital epidemiology, part II: chart use, statistical properties and research issues. Infection Control & Hospital Epidemiology 1998; 19: 265-283. (Pubitemid 128472675)
80. Lee K & McGreevey C. Using control charts to assess performance measurement data. Joint Commission Journal on Quality Improvement 2002; 28: 90-101.
81. Finison JL, Finison KS & Bliersbach CM. The use of control charts to improve healthcare quality. Journal of Health Care Quality Assurance 1993; 15: 9-23.
82. Benneyan JC. Statistical quality control methods in infection control and hospital epidemiology, part I: introduction and basic theory. Infection Control & Hospital Epidemiology 1998; 19: 194-214.
83. Schulz-Stubner S, Kelley J. Regional anesthesia surveillance system: first experiences with a quality assessment tool for regional anesthesia and analgesia.