British journal of anaesthesia
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Achieving good health outcomes for patients is the fundamental purpose of healthcare. What really matters to patients is the outcome of an intervention and the effect it will have on their wellbeing and life expectancy. After media coverage, and public enquiry into high mortality rates for paediatric cardiac surgery at the Bristol Royal Infirmary during the early 1990s, mortality rates for paediatric cardiac surgical procedures decreased dramatically both in Bristol and nationally. ⋯ There are issues around clinical coding, risk adjustment, the influence of clinical teamworking, and environmental factors. The National Institute of Academic Anaesthesia (NIAA) has identified that the description of clinical practice in anaesthesia and perioperative medicine is currently limited by a lack of valid, reliable quality measures. The NIAA suggests that there is a requirement for further research into identifying the anaesthetic outcome indicators which are most relevant to patients, and then benchmarking the performance of anaesthetic departments and anaesthetists.
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The concept of using a checklist in surgical and anaesthetic practice was energized by publication of the WHO Surgical Safety Checklist in 2008. It was believed that by routinely checking common safety issues, and by better team communication and dynamics, perioperative morbidity and mortality could be improved. ⋯ However, introducing surgical checklists is not as straightforward as it seems, and requires leadership, flexibility, and teamwork in a different way to that which is currently practiced. Future work should be aimed at ensuring effective implementation of the WHO Surgical Safety Checklist, which will benefit our patients on a global scale.
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Summary This article discusses how to estimate the risk of postoperative death, an outcome that affects an important minority of patients in the month(s) after scheduled surgery. In addition, it reflects on our inability to characterize the effects of surgery on quality of life. This outcome is of primary concern to the much more numerous survivors but is absent from all graphs of postoperative survival: it is the missing axis. The calculations discussed in the article are available online at https://sites.google.com/site/informrisk/.
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The decision of where to start a research project has been influenced by many factors over the years. Tradition has a large impact, but the individual researchers' or clinicians' personal interest has also played a major role. The pharmaceutical industries' interest has without doubt initiated and sponsored many projects in order to get new products onto the market. ⋯ One way of 'mapping' the evidence in order to find out what we know and what we do not know is the production of systematic reviews. Although systematic reviews are considered top of the evidence hierarchy, they are not flawless. The aim of this article is to explain the systematic review and point to some of the challenges in the development and use of systematic reviews.