C Rosenstock1, J Møller, A Hauberg. 1. Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark. rosenstock.c@dadlnet.dk
Abstract
BACKGROUND: In Denmark, a National Board of Patients' Complaints (NBPC) was founded in 1988. This study analyses anaesthetic complaints related to adverse respiratory events filed at the NBPC from 1994 to 1998 to point out directions for possible preventive measures. METHODS: All decisions made by the NBPC from 1994 to 1998 concerning personnel employed in the Danish health care system were scrutinized. Cases related to anaesthesia and intensive care medicine were reviewed. Adverse respiratory events were identified and classified by mechanism of the incident that had caused the complaint. Detailed information on anaesthetic technique, personnel involved, sequence of events, clinical manifestation of injury, and outcome was recorded. RESULTS: A total of 284 cases was identified. One-fifth (n=60) of the complaints were related to an adverse respiratory event. The overall mortality in these cases was 50% (n=30). In 19 complaints (32%), the treatment was considered substandard. CONCLUSION: Complaints related to respiratory events reveal that inadequate anaesthetic and intensive care medicine treatment leads to patient damage and death. Preventive strategies should be directed at the development of guidelines for handling the difficult airway, education in the management of the difficult airway, instruction in the correct use of anaesthetic equipment, improvement of interpersonnel communication routines, as well as implementation of simulator training.
BACKGROUND: In Denmark, a National Board of Patients' Complaints (NBPC) was founded in 1988. This study analyses anaesthetic complaints related to adverse respiratory events filed at the NBPC from 1994 to 1998 to point out directions for possible preventive measures. METHODS: All decisions made by the NBPC from 1994 to 1998 concerning personnel employed in the Danish health care system were scrutinized. Cases related to anaesthesia and intensive care medicine were reviewed. Adverse respiratory events were identified and classified by mechanism of the incident that had caused the complaint. Detailed information on anaesthetic technique, personnel involved, sequence of events, clinical manifestation of injury, and outcome was recorded. RESULTS: A total of 284 cases was identified. One-fifth (n=60) of the complaints were related to an adverse respiratory event. The overall mortality in these cases was 50% (n=30). In 19 complaints (32%), the treatment was considered substandard. CONCLUSION: Complaints related to respiratory events reveal that inadequate anaesthetic and intensive care medicine treatment leads to patient damage and death. Preventive strategies should be directed at the development of guidelines for handling the difficult airway, education in the management of the difficult airway, instruction in the correct use of anaesthetic equipment, improvement of interpersonnel communication routines, as well as implementation of simulator training.
Authors: Lars H Lundstrøm; Christophe Hv Duez; Anders K Nørskov; Charlotte V Rosenstock; Jakob L Thomsen; Ann Merete Møller; Søren Strande; Jørn Wetterslev Journal: Cochrane Database Syst Rev Date: 2017-05-17
Authors: Filippo Sanfilippo; Francesco Sgalambro; Giuseppe Chiaramonte; Cristina Santonocito; Gaetano Burgio; Antonio Arcadipane Journal: Turk J Anaesthesiol Reanim Date: 2019-09-02