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Multicenter Study Controlled Clinical Trial
Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study.
An interesting and thought-provoking study, even with its flaws.
The authors concluded that system changes surrounding anaesthetic drug delivery reduce medication error.
A ‘care bundle’ approach was taken to improve drug safety through system design and human factors considerations:
- Coloured drug labels with barcodes.
- Computerised drug crosscheck.
- Computerised allergy and drug expiration alerts.
- Re-organised anaesthesia workplace, focusing on the drug administration workflow.
- Prefilled syringes for: calcium chloride, ephredrine, fentanyl, lidocaine, magnesium sulphate, metaraminol, midazolam, neostigmine, and pancuronium.
- Automated computerised anaesthetic record.
But the problems...
No randomisation, no blinding, observational study, completely voluntary use of the safety system and self-reporting of errors...
Were the improvements due to the intervention, or simply a greater interest and priority given to anaesthetic safety? (Would it matter?)
In only 15% of anaesthetics was the new system (voluntarily) used, and thus may represent anaesthetists more motivated to prioritise medication safety over convenience or convention.
Finally error is being used (not unreasonably) as a surrogate marker for patient harm. (Although the authors did try to sneak in... “a non-significant reduction (p=0.055) in the harm attributable to drug administration error” 🙄)
Final word of caution
Even this quite impressive system was not immune to error. There were 19 cases of violation of the video and/or audio crosscheck before drug administration. Automated safety systems are obviously no panacea.
Additionally, although there was an observed reduction in all drug errors, there was no reduction specifically in drug substitution error.
Nonetheless a refreshing and novel approach to anaesthetic drug safety, beyond the typical admonishment to just be safer.
More on the system used:
- Webster (2001): The frequency and nature of drug administration error during anaesthesia
- Merry (2001): A new, safety-oriented, integrated drug administration and automated anesthesia record system
- Webster (2004): A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods.
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The researchers performed multiple cross-sectional surveys of three years of US anesthesiology trainees, from their first year of clinical anesthesia training to a year after qualification. They surveyed the anesthesiologists for burnout, distress and depression.
Burnout, distress and depression were worryingly common (51%, 32% and 12% of residents), although self-reported availability of workplace resources to manage burnout & depression, and perceived work-life balance were protective, roughly halving odds of each outcome.
Having strong social supports was also associated with lower rates of depression and burnout, although not distress.
Both working more hours each week and having larger student loan debt were associated with depression and distress, although not burnout.
Females, although only making up 37% of respondents, were more likely to suffer from burnout and depression. International medical school graduates were in contrast less likely.
The take-home message...
Burnout, distress and depression are common among anesthesiology trainees and newly qualified anesthesiologists. Workplace support, efforts to maintain work-life balance, maintaining social supports and limiting working hours are modifiable factors that have protective effects.
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Who are EM3?
EM3 or ‘East Midlands Emergency Medicine Educational Media’ is an online emergency medicine educational resource, based out of Leicester Royal Infirmary ED. While their web presence is the foundation of their online resources, they are most interesting for the very successful way they translate emergency medicine research and education through multi-platform social media and FOAMed.
So, what happened?
In late October there were two inadvertent errors in educational resources simultaneously posted by EM3 to Twitter, Instagram, Facebook and Reddit. The errors were quickly identified and corrected, but despite this the incorrect posts continued to be shared, reaching some 15,000 people.
Edwards and Roland carefully describe the events, the approach EM3 took to correcting the errors, and analysis of the potential impact. They discuss the challenges when correcting what is by its very nature a dynamic resource, and one for which there is limited control once released. EM3 discuss the additional oversight added to their peer review process in response.
Their report is a cautionary tale for the FOAMed community and a useful resource for avoiding and managing SM errors when they inevitably occur.
Don’t be hasty...
Acknowledging that the reach and velocity offered by social media and FOAMed also bring accuracy and credibility concerns, traditional academic publishing is not without its own problems.
Whether outright academic fraud, replication crises or information overload, we already know that incorrect medical information persists for decades after being disproven. This is not a new problem, though FOAMed does accelerate the speed and scope for both good and bad.
Between the lines
The context of the article’s publication reveals the ongoing tension between FOAMed and the reality of traditional academic publishers, such as the BMJ: ‘Learning from mistakes on social media’ is not itself open access...
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Multicenter Study Observational Study
The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.
Mild to moderate pre‐operative hypertension is not associated with peri-operative haemodynamic instability.
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Acta Anaesthesiol Scand · Jul 2014
Randomized Controlled Trial Comparative StudyDexamethasone for pain after outpatient shoulder surgery: a randomised, double-blind, placebo-controlled trial.
Preoperative IV dexamethasone reduces pain after arthroscopic shoulder surgery.
pearl