Spreading the risk: a look at what other medical journals are reporting

Twelve steps to safer patient care

A systematic review of studies on in-hospital adverse events, covering nearly 75,000 patients found an overall rate of 9.2% with nearly half adjudged preventable. While half of patients suffered little or no harm, 7.4% died. The majority of problems were related to operations or medication, so the authors recommend concentrating on these areas within hospital safety programmes.

Recognized evidence-based interventions are listed. For surgery, these include:

localizing care in high-volume centres;

Barely two cheers for perioperative beta blockers

The systematic review detailed above suggested perioperative beta blocker use was backed by strong evidence. While this is true, over the years some study results were less persuasive than others and many clinicians remain unconvinced. Recently, the Lancet published the results of the POISE trial, a large multinational randomized placebo-controlled trial of this group of drugs with over 8000 patients being randomized. That study found that for every 1000 patients undergoing non-cardiac surgery who are given perioperative beta blockers, 15 will be spared a myocardial infarction, 3 from needing coronary revascularization and 7 from developing atrial fibrillation – but an extra 8 will die and 5 have a stroke.

This month, a group of authors who collected data for the POISE study summarize their personal take home messages in a leading anaesthetic journal.

Patients already on these drugs before operation should stay on them;

Ambulance services litigation risk quantified

From 1995–2005, the NHSLA handled 272 cases of litigation against UK ambulance services. The annual rate has increased fivefold over the period. In 75 cases the allegation was of lack of assistance or care and in 36 and 34, respectively, failure or delay in treatment and in diagnosis. Seventeen claims, mostly ongoing, were for over £1 million.

Assistance problems related in many cases to adverse incidents, such as falls during the transfer, including from wheelchairs and stretchers. There were 34 allegations of failing to immobilize (or incorrectly immobilizing) the spine, allegedly resulting in one death and 19 patients suffering neurological deficits. Delay was alleged in 42 cases, with meningitis being a notable component.

By February 2005, 187 cases had settled, 70 without a payment (with one patient held responsible for costs). Of the 17 large claims, eight were still open and 9 ‘on hold’. The 13 obstetric cases included four where lack of equipment to handle a premature baby or failure to recognize and treat neonatal hypoxia was a factor.

The findings suggest key training areas for paramedics and other ambulance personnel include obstetric care, how to recognize spinal cord injury and greater attention to decisions on not transferring patients to hospital. Joint Royal College Ambulance Liaison Committee guidelines have addressed the first two of these (see http://www.2.warwick.ac.uk/fac/med/research/hsri/emergencycare/jrcalc_2006/guidelines/). Major areas for organizational change relate to reducing delay and providing safe transfer.

Emergency Medicine Journal 2008; 25: 455–8

Supporting clinicians after a patient disaster

We tend to forget that clinicians involved in a serious adverse event may need help and support at a stressful time in their lives. A paper from Virginia, published in the Patient Safety section of Anesthesia & Analgesia, reminds us that most anaesthetists will experience a ‘death on the table’ at least once in their career – handling the aftermath of which may not have been part of their training. Surveys have shown that death of a patient may have a major emotional impact on healthcare practitioners involved, regardless of whether the death was unexpected or the patient well-known to the practitioner. Those in the early part of their training are worst affected. Given that anaesthetists are at disproportionate risk of suicide and substance abuse, the authors suggest they may be a group particularly susceptible to stress-related disorders. Unsurprisingly, therefore, surveys have shown that a patient's death may lead to prolonged psychological distress with recovery hampered by lack of emotional and professional support.

The authors recommend putting into practice guidelines for support such as those issued by the Association of Anaesthetists of Great Britain and Ireland (see http://www.aagbi.org/). They also call for more research into the impact of perioperative catastrophes on providers and healthcare systems, with education and support for practitioners at risk. Further, the ‘Adverse Event Protocol’ on the website of the Anesthesia Patient Safety Foundation (see http://www.apsf.org/) suggests how to minimize patient injury and identify the causes of adverse events.

Anesthesia & Analgesia 2008; 107: 591–600

Reducing the risk of Erb's palsy

A common reason for litigation in neonatal medicine is because of Erb's palsy, partial paralysis of a newborn baby's arm following traction injury to nerves of the brachial plexus running through the axilla. It is a particular problem with large babies where there is difficulty in delivering the shoulders (shoulder dystocia). Specific training in avoidance is mandated by the Clinical Negligence Scheme for Trusts in the UK (and recommended by the organization which accredits healthcare organizations in the US) but, until now, there has been no evidence of any associated improvement in outcome post-training.

A study from Bristol has compared the management and outcome of shoulder dystocia from 1996–1999 (before training was introduced) and 2001–2004 when staff received appropriate training during a multidisciplinary one-day course, including a 30-minute individual practical session on a mannequin. The dystocia rate (about 2% of all vaginal births) was similar in both periods, during which there were over 29,000 eligible deliveries.

Before training, the obstetric notes disclosed that in 50% of cases none of the manoeuvres recommended for handling shoulder dystocia were used (McRoberts' position, suprapubic pressure, internal rotation, delivery of the posterior arm, All-Fours-manoeuvre). Post-training, at least one of these was used in 90%. There was also marked reduction in descriptions suggesting excessive traction might have been used.

Brachial plexus injury at birth was reduced from 7.4% of babies with shoulder dystocia to 2.3%. Persistent brachial plexus injury at 6 and 12 months were fewer but the number did not reach statistical significance, possibly because of small numbers – with only 9 and 6 babies, respectively, pre-training and 2 and 2 post-training. The authors point out that studies published from three other UK hospitals have shown increases in brachial plexus injuries over the period in question. They believe they may have had greater success by mandating training for all staff and carrying it out in a labour suite, which is where the emergency usually occurs.

Obstetrics & Gynecology 2008; 112: 14–20