Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study.
The Australian Incident Monitoring Study database was examined for incidents involving inadequate pre-operative patient preparation and/or evaluation. Of 6271 reports, 727 had appropriate keywords, of which 197 (3.1%) were used for subsequent analysis. All surgical categories were represented. In 10% of reports the patient was not reviewed pre-operatively by an anaesthetist, whilst in 23% the anaesthetist involved in the operating theatre had not performed the pre-operative assessment. Death followed in seven cases, major morbidity in 23 cases, admission to a high-dependency unit or intensive care unit in 17 cases, and surgery was cancelled in nine cases. Poor airway assessment, communication problems and inadequate evaluation were the most common contributing factors. Respondents indicated that the incident was preventable in 57% of cases. Proposed corrective strategies include improved communication, quality assurance activities, development of protocols and additional training. A structured assessment of the airway, along with improvements in information exchange, patient assessment, and use of clearly defined patient management plans and pathways would prevent most of the incidents reported.
Kluger
M T
MT
Specialist Anaesthetist, Department of Anaesthesia, North Shore Hospital, Auckland, New Zealand; Consultant Anaesthetist, and Professor, Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, Australia; Specialist Anaes.
Tham
E J
EJ
Coleman
N A
NA
Runciman
W B
WB
Bullock
M F
MF
D000776:Anesthesiology / Q000592:standards*; D001315:Australia / Q000453:epidemiology; D002985:Clinical Protocols; D003422:Critical Care / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008499:Medical Records / Q000592:standards; D010343:Patient Admission / Q000706:statistics & numerical data; D011300:Preoperative Care / Q000592:standards*; D011785:Quality Assurance, Health Care; D012307:Risk Factors; D012308:Risk Management