Permanent Harm Research Articles

Awake Craniotomy for Tumor Resection: Further Optimizing Therapy of Brain Tumors.

In recent years more and more data have emerged linking the most radical resection to prolonged survival in patients harboring brain tumors. Since total tumor resection could increase postoperative morbidity, many methods have been suggested to reduce the risk of postoperative neurological deficits: awake craniotomy with the possibility of continuous patient-surgeon communication is one of the possibilities of finding out how radical a tumor resection can possibly be without causing permanent harm to the patient.In 1994 we started to perform awake craniotomy for glioma resection. In 2005 the use of intraoperative high-field magnetic resonance imaging (MRI) was included in the standard tumor therapy protocol. Here we review our experience in performing awake surgery for gliomas, gained in 219 patients.Patient selection by the operating surgeon and a neuropsychologist is of primary importance: the patient should feel as if they are part of the surgical team fighting against the tumor. The patient will undergo extensive neuropsychological testing, functional MRI, and fiber tractography in order to define the relationship between the tumor and the functionally relevant brain areas. Attention needs to be given at which particular time during surgery the intraoperative MRI is performed. Results from part of our series (without and with ioMRI scan) are presented.

342 72-Hour Returns: A Trigger Tool for Diagnostic Error

Patients who return to the emergency department (ED) within 72 hours of discharge are thought to represent failures in diagnosis, treatment and discharge planning. As a result, this metric is often seen as a surrogate for quality and used for ED quality assurance efforts. Little is known about the yield of this kind of review and the types of errors it identifies. The objective of this study was to identify the prevalence of error deficient care in patients who return within 72 hours and require admission, as well as the types and severity of harm in these patients. Retrospective review of all patients who presented to an urban, university-affiliated ED between October 1st, 2012 and September 30th, 2015 who were evaluated, discharged, and returned within 72 hours requiring hospital admission. As a part of departmental quality assurance activities, the records were reviewed by attending physician members of the Quality and Safety Committee. Any visit felt to represent substandard care was flagged for further investigation. These cases then received a secondary review by a different ED attending who classified the deviation in care for this study, if present, using a standard classification system. There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72 hours and were admitted to the hospital. An event requiring further investigation was identified in 59 of these patients (2.95% of all 72-hour returns), and 50 of them (2.49% of all 72-hour returns and 0.0119% of all ED visit) were deemed to represent a deviation from optimal care (see Figure 1). Of these cases, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these 48 encounters, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%), including a failure to obtain a complete history and conduct a complete physical exam (3 cases, 6.2%), failure of ongoing monitoring of clinical status (4 cases, 8.3%), failure to establish a differential diagnosis (20 cases, 41.6%) and failure to order the appropriate diagnostic test (2 cases, 4.1%). The remainder of the cases represented failures in completing testing and results processing (13 cases, 27%), and failures in follow-up and coordination (6 cases, 12.5%). When the National Patient Safety Foundation’s Error Severity Codes were applied to the 50 cases that represented deviations from optimal care, 12 (24%) resulted in minor temporary harm, 30 (60%) in major temporary harm, 4 (8%) in minor permanent harm, 1 (2%) in major permanent harm and 3 (6%) resulted in death. Standard screening methodology of 72-hour ED returns resulting in admission has relatively low yield in identifying suboptimal care, with less than 3% of cases reviewed representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. As such, these reviews may be useful as a tool for ongoing professional practice evaluation of individual clinicians, however likely serve less value in identifying departmental systems issues contributing to unsafe care. Future study should focus on understanding the yield of other departmental QA triggers such as safety reports and morbidity and mortality conferences.

Retinal Injury Secondary to Laser Pointers in Pediatric Patients

This case report describes 4 male children (age, 9-16) who had laser-related retinal injury to the macula of 1 eye or both eyes due to the mishandling of the laser pointer devices at a single vitreoretinal clinical practice. The presenting symptoms associated with laser pointer injury include central vision loss, central scotoma, and metamorphopsia. Clinical findings of laser-related retinal injury include reduced visual acuity, disruption of the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy, and choroidal neovascular membrane formation. Disruption of the foveal ellipsoid zone (photoreceptor inner segment/outer segment layer) is the most common finding on optical coherence tomography imaging. Three patients had potential irreversible vision loss. Laser pointers are readily available and appropriate use of laser pointers in the pediatric population must be emphasized due to the potential irreversible retinal injury. Health professionals, school teachers, and parents should raise public awareness of this emerging public health issue by educating children about the dangers of laser pointers. Laser pointer devices among children should be discouraged and limited due to the possibility of permanent harm to themselves and others. Legislation and laws may be required to better control the sale and use of these devices.

Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

- Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department. - Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient. - All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.

Identifying Medication-Related Adverse Drug Events in Nursing Facilities in East Texas.

The purpose of this study was to identify the rate of adverse drug events (ADEs) and the percentage that cause harm in east Texas nursing facilities. In 2014, there were 1.4 million nursing facility residents in the United States, and approximately half take nine or more prescribed medications daily. Twenty percent of medication doses administered results in an error, putting almost half of all nursing home residents at risk for two or more medication errors daily. Close to two million medication error-related ADEs are estimated to occur in nursing facilities each year. Many ADEs lead to emergency department visits and hospitalization. A two-month retrospective medical chart review was completed in two medium-sized for-profit nursing facilities in rural east Texas on residents who consented or whose proxy consented to the study. The Nursing Home Adverse Drug Event trigger tool was used for chart reviews. This tool primary uses laboratory values and resident assessments to identify medication-related ADEs. A total of 58 charts were reviewed. There were from 2 to 13 ADEs identified per month at the nursing facilities during the study. This was extrapolated to 7.41 to 27.59 ADEs per 100 resident months. While no permanent harm or hospitalizations resulted from the identified ADEs, these findings in such a small sample size contribute to an elevated level of concern about ADE occurrence and prohibit generalizability of results. Further research is needed on a larger sample, as well as types of medication errors occurring, leading to strategies for preventing ADEs.

Self-activating liquid crystal devices for smart laser protection

ABSTRACTLasers are now extensively used in a multitude of optical devices and photonic systems spanning from sensing, communication, entertainment, medical surgery to military applications. Direct accidental or intentional exposures to high power lasers may lead to severe temporary or even permanent harm of human eye, skin, or optical sensors. The effective laser protection and shielding are currently not only a subject of scientific research but also a potential public safety issue, therefore there is an urgent need to develop the intelligent laser protection devices for keeping human eyes, optical sensors, and other sensitive components from these unintended or intended damages by laser radiations without warning. Self-activating liquid crystal devices undoubtedly represent such an elegant example because they could be autonomously activated to block or attenuate the lasers when the laser intensity is higher than a maximum permissible exposure value. This review is devoted to summarising the up-to-date significant advances of self-activating liquid crystal devices for potential smart laser protection, including twist-aligned nematic liquid crystal devices, liquid crystal cored waveguide fibre arrays, and photovoltaic/pyroelectric-hybridised liquid crystal devices. Finally, the review concludes with the perspectives and challenges for the future development of self-activating liquid crystal devices. It is anticipated that this glimpse and further endeavours in the emerging field will help the researchers from different backgrounds towards the fabrication of highly efficient laser protection devices, their real-world widespread applications and beyond.

Preventable Adverse Events in Surgical Care in Sweden: A Nationwide Review of Patient Notes.

Adverse events (AEs) occur in health care and may result in harm to patients especially in the field of surgery. Our objective was to analyze AEs in surgical patient care from a nationwide perspective and to analyze the frequency of AEs that may be preventable.In total 19,141 randomly selected admissions in 63 Swedish hospitals were reviewed each month during 2013 using a 2-stage record review method based on the identification of predefined triggers. The subgroup of 3301 surgical admissions was analyzed. All AEs were categorized according to site, type, level of severity, and degree of preventability.We reviewed 3301 patients’ records and 507 (15.4%) were associated with AEs. A total of 62.5% of the AEs were considered probably preventable, over half contributed to prolonged hospital care or readmission, and 4.7% to permanent harm or death. Healthcare acquired infections composed of more than one third of AEs. The majority of the most serious AEs composed of healthcare acquired infections and surgical or other invasive AEs. The incidence of AEs was 13% in patients 18 to 64 years old and 17% in ≥65 years. Pressure sores and drug-related AEs were more common in patients being ≥65 years. Urinary retention and pressure sores showed the highest degree of preventability. Patients with probably preventable AEs had in median 7.1 days longer hospital stay.We conclude that AEs are common in surgical care and the majority are probably preventable.

Rating and Classification of Incident Reporting in Radiology in a Large Academic Medical Center

The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs.

The high rate of long-term recurrences and sequelae after epistaxis treatment

Epistaxis is the most frequent rhinologic emergency with a high treatment morbidity. This study assessed the long-term outcome after epistaxis treatment with regard to patient comfort during the treatment, long-term complications and rate of recurrences. A questionnaire cohort study was performed at the ENT department of the University Hospital Zurich. In April 2014, 363 patients were contacted, who were treated between March 2007 and April 2008 for the reason of epistaxis using a written questionnaire to elucidate the patients' condition after the treatment. The type of treatment, subjective discomfort as well as degree of pain, complications, permanent sequelae and recurrences were assessed. 109 questionnaires were analyzed (response rate of 36%). The overall same-sided recurrence rate after successful treatment during the 6.4-year follow-up was 22%. Discomfort was reported in 48% after cautery, 86% after packing and in 11% after surgery. Strong or very strong pain was perceived in 8% after cautery, 26% after packing and in 0% after surgery alone. Complications consisted of nasal crusting in 15% after cautery and nasal breathing impairment in 24% after packing. Permanent harm was reported in 4% after cautery versus 20% after packing plus surgery. The data confirm the high rate of recurrences despite adequate treatment in the long-term analysis. The rate of post-treatment complications is considerably high with nasal crusting being the main inconvenience. It further shows that patients keep a vivid memory of the treatment even many years later and that packing is extremely uncomfortable to patients.

Rates of safety incident reporting in MRI in a large academic medical center.

To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

Pain after surgery in children: clinical recommendations.

This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions. Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.

Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

An analysis of dental patient safety incidents in a patient complaint and healthcare supervisory database in Finland

Objective. Few studies of patient harm and harm-prevention methods in dentistry exist. This study aimed to identify and characterize dental patient safety incidents (PSIs) in a national sample of closed dental cases reported to the Regional State Administrative Agencies (AVIs) and the National Supervisory Authority for Welfare and Health (Valvira) in Finland. Materials and methods. The sample included all available fully resolved dental cases (n = 948) during 2000–2012 (initiated by the end of 2011). Cases included both patient and next of kin complaints and notifications from other authorities, employers, pharmacies, etc. The cases analyzed concerned both public and private dentistry and included incident reports lodged against dentists and other dental-care professionals. Data also include the most severe cases since these are reported to Valvira. PSIs were categorized according to common incident types and preventability and severity assessments were based on expert opinions in the decisions from closed cases. Results. Most alleged PSIs were proven valid and evaluated as potentially preventable. PSIs were most often related to different dental treatment procedures or diagnostics. More than half of all PSIs were assessed as severe, posing severe risk or as causing permanent or long-lasting harm to patients. The risk for PSI was highest among male general dental practitioners with recurring complaints and notifications. Conclusions. Despite some limitations, this register-based study identifies new perspectives on improving safety in dental care. Many PSIs could be prevented through the proper and more systematic use of already available error-prevention methods.

The Story of "Speed" from "Cloud Nine" to Brain Gain.

The substituted amphetamines have had a checkered medical history intertwined with a sensational cultural history. Mankind's insatiable fascination with speed has led to widespread misuse sometimes with disastrous neurological and psychiatric consequences that may cause a permanent harm but their potential to enhance cognition should not be dismissed or forgotten. Further, smarter research could perhaps still lead to an expanded beneficial role for stimulant use in modern society.

Safety of Early Enrollment into Outpatient Cardiac Rehabilitation After Open Heart Surgery

The safety of early enrollment (<2 weeks after hospital discharge) into cardiac rehabilitation (CR) after recent coronary artery bypass graft (CABG) surgery or heart valve surgery (HVS) has not previously been assessed and has important policy implications. Consequently, we performed a detailed review of all clinical adverse events within 6 months of hospital discharge. We compared early and late attendees for patients undergoing CABG surgery or HVS and included patients with myocardial infarction (MI) as an additional control group. We analyzed 112 patients undergoing CABG surgery, 69 patients undergoing HVS, and 59 patients with MI. Median time (interquartile range) from hospital discharge to CR enrollment was 10.5 (8 to 15), 12 (8.5 to 21), and 9 days (7 to 14), respectively. There was no difference in major event rates between early and late enrollees (17% vs 17%, respectively, log-rank p = 0.98) or by diagnosis (15%, 16%, and 22% for CABG surgery, HVS, and MI, respectively; log-rank p = 0.50). Sternal instability and wound infection rates were similar. CR-related adverse events trended toward increased event rates in surgical and early enrollees, but of 44 events, only 3 were exercise related, none resulted in permanent harm, and 41 (93%) were managed in CR without need for emergency services. In conclusion, it appears that a policy of encouraging early enrollment into CR in patients with a recent open heart surgery seems unlikely to harm patients when careful individualized assessment and exercise prescription take place within the bounds of an established CR program.

Medically assisted circumcision: a safer option for initiation rites.

[Extract] Culturally sensitive integration of medical circumcision could avert adverse effects at traditional male initiation rites. In many traditional cultures, male initiation rites involve circumcision practices that can sometimes result in medical complications. In a recent incident in the Northern Territory, three young men required airlifting from their Borroloola initiation site to Darwin for medical assistance. The risk of permanent harm and potentially fatal outcomes could be decreased if safer options were available during initiation ceremonies. In this article, we report that it is possible to provide safe circumcision at male initiation rites.

Relevance of foreign alerts and newsletters for the medication errors reporting programme in the Netherlands: an explorative retrospective study.

National reporting programmes usually collect and analyse medication error reports from healthcare providers in their own country and only disseminate guidance to healthcare providers within the borders of their country. It is unclear how much different national programmes could learn from each other. The aim of this study was therefore to explore to what extent alerts and newsletters about medication errors issued in other countries could also be relevant for the Netherlands. Ninety disseminated information items that had been issued by three national programmes (Canada, the US and the UK) in the period from June 2009 until June 2012 were collected. These items were compared with the national reporting programme Central Medication Incidents Registration (CMR-NL) in The Netherlands. Each selected item was subsequently assessed independently with six assessment criteria: is the medicine available in the Netherlands? If so, could a similar error occur in the Netherlands? Did the CMR-NL reporting programme receive any reports about a comparable (or even identical) error? If so, did these reports include any errors with serious temporary or permanent harm? Did the CMR-NL disseminate output about it?; If so, what was the dissemination date of CMR-NL? From the 90 items, 87.8% (n=79) were relevant for Dutch healthcare. For 43 of the 90 items (47.8%), the CMR-NL had received comparable (or even identical) errors but had not disseminated any alert or newsletter about these errors. The CMR-NL had disseminated an alert or newsletter for 14 of the 90 items (15.6%). This study showed for a broad range of errors that the Dutch national reporting programme could learn from the three reporting programmes in Canada, the US and the UK. National reporting programmes can benefit from sharing alerts and newsletters that enhance the learning between countries.

Managing Maternal Cardiac Arrest in Canada

Fortunately, maternal mortality is a rare occurrence in the developed world and even more uncommon when the mortality is due to maternal cardiac arrest – the estimated rate is 1:20,000-1:30,000 pregnancies. When maternal cardiac arrest occurs, the lives of both the parturient and fetus are at risk. Consequently, there is a very brief window of opportunity for return of hemodynamic stability before the risk of permanent harm to the mother and fetus begins. Despite parturients being younger than the typical patient experiencing cardiac arrest, there are a variety of complex reasons why survival is reported at less than 10%. Substandard care, poor resuscitation attempts, and lack of compliance with accepted resuscitation algorithms have been common themes in the Centre for Maternal and Child Enquiries (CMACE) triennial reports out of the United Kingdom (UK). Importantly, commentary and management strategies have followed the publication of each report, and progress has been made over time to improve how providers manage these rare events. In 2000, the American Heart Association (AHA) clearly spelled out the rationale to advocate proceeding with an emergent Cesarean delivery after four minutes of maternal cardiac arrest. In 2010, the AHA developed a separate maternal cardiac arrest algorithm. While it is true that the evidence – first put forth in 1986 – is from case series and there will always be individual cases where a longer period of lack of blood flow to the uterus still results in a live intact neonate, it has been reported that a fetus more than 24-25 weeks’ gestation experiencing more than ten minutes of absent blood flow will generally experience neurological (and other) deficits. More importantly, evacuation of the gravid uterus makes successful maternal resuscitation much more likely regardless of gestational age. In a resuscitation scenario during which the application of good-quality chest compressions produces no palpable maternal pulse, uterine evacuation should be expedited. The release of aortocaval compression and autotransfusion effects may potentially facilitate attempts at maternal resuscitation. In this issue of the Journal, Baghirzada and Balki describe the experience with maternal cardiac arrest in their Canadian institution over a 12-year period. One of their conclusions is that the four-minute rule need not be applied too rigorously, as they provide evidence for intact neonatal survival up to 14 min after loss of maternal circulation. These observations are consistent with other case reports. The authors not only identified poor documentation for each of the five cases, but they also reported the difficulty in organizing and mobilizing the team to initiate the emergent Cesarean delivery within four minutes post-arrest. Rather than conclude that perhaps it is acceptable to delay the decision and start of surgery, there are other lessons to be learned; for example, all practitioners practicing in a hospital providing obstetrical services need to carry out a critical appraisal of their overall readiness to manage maternal cardiac arrest. If there are no clear, concise, and precise guidelines, it has been well documented that the entire team will be challenged to proceed in a protocol during management of cardiac arrest in any patient. This is recognized in the latest R. Preston, MD (&) Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Rm 3300 JPPN, 910 W 10th Avenue, Vancouver, BC V5Z 1M9, Canada e-mail: roanne.preston@ubc.ca

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit

ObjectiveTo determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding...

AN AUDIT TO ASSESS ADHERENCE TO HOSPITAL PRESCRIBING GUIDELINES IN A TERTIARY PAEDIATRIC INTENSIVE CARE UNIT

AimsThe aims of the audit were to:Assess the level of adherence to hospital prescribing guidelines in the Paediatric Intensive Care Unit (PICU).Identify the areas of greatest and least adherence.Identify any...