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Patient safety in anaesthesia: assessment of status quo in the Berlin-Brandenburg area, Germany

Balzer, Felix; Spies, Claudia; Schaffartzik, Walter; Pappert, Dirk; Wernecke, Klaus-Dieter; Kuhly, Rainer; Boemke, Willehad

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European Journal of Anaesthesiology: October 2011 - Volume 28 - Issue 10 - p 749-752
doi: 10.1097/EJA.0b013e328348ee35

Introduction

According to a recent systematic review of 74 485 patient records, the overall incidence of in-hospital adverse events was found to be 9.2%. Of these, 43.5% were thought to be preventable if proper safety measures had been applied.1

Patient safety instruments (e.g. checklists, critical incident reporting systems) are already frequently used in anaesthesiological perioperative environments,2,3 but for a long time, there have not been precise recommendations concerning which of the evidence-based safety concepts are indispensable. Launched in June 2010 by the European Board of Anaesthesiology (EBA) and the European Society of Anaesthesiology (ESA), the Helsinki Declaration on Patient Safety in Anaesthesiology has been a tremendous step in this direction (http://http://www.euroanesthesia.org/sitecore/content/Publications/Helsinki%20Declaration.aspx).

We aimed to assess the status quo of the implementation of the Declaration's principle in the Berlin-Brandenburg region, Germany. All anaesthesiological departments of the ‘Innovationsallianz für Anästhesiologie Berlin-Brandenburg’ (INABBRA) were invited to take part, representing a regional network comprising 31 hospitals of different care levels and operators (http://http://www.inabbra.de). Founded in 2009, INABBRA aims to advance the cooperation of individual hospitals and to implement innovative projects in residential training and scientific research.

The survey was registered through Clinicaltrials.gov (identifier: NCT01246544), approved by the data protection committee and the ethics committee of the Charité, Berlin, Germany, on 25 November 2010 (EA1/261/10; Chairperson Professor R. Uebelhack).

For the survey, an online questionnaire with a server-based software (LimeSurvey, version 1.82+) was used. After an acquisition period of approximately 6 weeks, 28 completed questionnaires from the 31 Anaesthesia Departments of the INABBRA hospitals were received.

The results show that many safety standards of the Helsinki Declaration on Patient Safety in Anaesthesiology are already applied (for details, see Table 1 and Fig. 1).

Table 1
Table 1:
Questionnaire and results
Fig. 1
Fig. 1:
no caption available.

Monitoring

Ninety-three percent of the participating hospitals run a recovery room that is in most cases used only during core times (57%). Unlike the operating rooms, 8% of the recovery rooms lack ECG monitoring and 38% have no capnometry devices.

Protocols

Preoperative assessment and preparation is the only procedure for which protocols exist in every hospital of the INABBRA network.

Checklists

Support of the ‘WHO Safe Surgery Saves Lives Initiative’ is demanded in the Helsinki Declaration. Although none of the participating hospitals uses the checklist in its original form, 82% of them have deployed a modified version.

Annual safety report

An annual safety report is issued in 19% of the participating hospitals. The content of these safety reports varies considerably (measures taken are described in 50% of all reports, the results of the measures in only 33%).

Report on morbidity and mortality

Morbidity and Mortality conferences are regularly held at 60% of the INABBRA hospitals. Seventy percent of these hospitals have established feedback mechanisms, and 93% discuss improvement measures. However, only one-fifth of these hospitals publish results in an annual report.

Critical incident reporting systems

An anonymous system for assessing critical incidents is used by 60%. Eighty percent of them forward the acquired data to the national authority evaluating critical incidents, and 69% of them present critical incident reporting systems data in an annual report.

Sedation

According to the Helsinki Declaration, the administration of sedatives by other departments has to comply with anaesthesiologically approved standards. Whether or not the different non-anaesthesiological departments of a specific hospital use standards can rarely be answered by the anaesthetist. The answer here, therefore, aims at whether the department of anaesthesiology follows such standards or guidelines.4 Sixty one percent declared that they follow a standard or guideline.

Peer review and quality management

The last section of our questionnaire was about peer review and quality management. Thirty-nine per cent of all hospitals take part in peer review or other accreditation processes. KTQ (http://http://www.ktq.de) has been the most frequently applied system.

Discussion

The overall incidence of severe adverse events in the domain of anaesthesiology is relatively low. Studies have shown that between 1969 and 1988, the rate of anaesthesia-related cardiopulmonary arrests decreased by 48%,5 and mortality in Europe, Australia and the United States is nowadays 1 : 100 000 cases, not least due to the introduction of pulse oximetry and capnography. Although mortality in the perioperative environment is fairly low, morbidity is still comparatively high. The likelihood of severe perioperative or postoperative complications with permanent damage is estimated to be one per 170–500 patients.6

Considering the four columns of our specialty (i.e. anaesthesia, intensive care, emergency medicine and pain therapy), it has been shown that in Germany, approximately 75% of the adverse events are witnessed in the field of ‘anaesthesia’ – mostly airway related, for example laryngeal/dental damages, and aspiration, and the second most complications after regional anaesthesia, most severly paraplegia.4 We have to keep in mind that such consequences may affect patients of any ASA type and hence may be responsible for serious damage in people of fairly good health prior to their medical procedure. The Helsinki Declaration on Patient Safety may serve to prevent these negative outcomes.

Acknowledgements

The authors thank Günther Jonitz, Chairman of Berlin's Medical Association, and Udo Wolter, Chairman of Brandenburg's Medical Association, as well as the heads of the Anaesthesiology Departments of the INABBRA hospitals for their support.

None of the authors received financial support or sponsorship for this survey, and there are no conflicts of interest.

References

1. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Healthcare 2008; 3:216–223.
2. Schlack WS, Boermeester MA. Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice. Curr Opin Anaesthesiol 2010; 6:754–758.
3. Smith AF, Mahajan RP. National critical incident reporting: improving patient safety. Br J Anaesth 2009; 5:623–625.
4. Schaffartzik W, Neu J. Injuries in anaesthesia. Anaesthesist 2007; 56:444–448.
5. Keenan RL, Boyan CA. Decreasing frequency of anesthetic cardiac arrests. J Clin Anesth 1991; 3:354–357.
6. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol 2010; 7:592–597.
© 2011 European Society of Anaesthesiology