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Biomedical subjects

C S Webster

Publications and source records attributed to C S Webster.

At least 19 recordsLinked to original sources
PubMed2006

A national survey of infection control practice by New Zealand anaesthetists.

Anaesthetists have an important role in preventing nosocomial infection. Failures in this role have resulted in critical reports in the media. We ascertained the current practices of New Zealand anaesthetists relating to infection control, by distributing a questionnaire to all 450 anaesthetists practising in New Zealand. Sixty-one percent responded. Just over half the respondents had never read their hospital policy on infection control and over a third had never read the Australian and New Zealand College of Anaesthetists policy document on infection control. It was found that 3.4% rarely changed gloves if they became contaminated and 2.2% occasionally used the same syringe to administer drugs to more than one patient. The majority (86.3%) of respondents split one drug ampoule between more than one patient, 41.3% used multidose vials for more than one patient and 2.2% used pre-filled syringes for more than one patient. The majority complied with the College infection control policy for performing arterial cannulation (85.7%), central venous cannulation (77.4%) and regional blockade (65.1%). Respondents ranked the overall risk of the anaesthetist contributing to the transmission of infectious agents on a scale from 0 to 10 (10=highest risk). The median response was 7, the modal response was 10 and interquartile range was 4 to 8. There was a high level of awareness of the risks of contributing to cross-infection inherent in anaesthesia, most anaesthetists reporting that they followed recommended guidelines in this context. However, these data suggest more effort is required to promote compliance with appropriate guidelines.

Anesthesia↗
PubMed2005

Transient fixation on a non-native language associated with anaesthesia.

We report a patient with the unusual language disturbance of transient fixation on a non-native language after otherwise uneventful general anaesthesia. The patient was unable to speak his native language for a period of 5-10 min, despite a desire to do so. He fully and spontaneously recovered from the episode. The phenomenon raises a number of interesting questions about the nature of human language, anaesthesia and consciousness. We discuss our patient in the context of some of these questions and present a review of three similar patients reported in the anaesthetic literature.

Anesthesia, General↗
PubMed2005

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.

Safety practices in health care have not kept pace with the increasing complexity of medical technology. Although anaesthesia is generally considered to be a leader in the improvement of patient safety, more powerful safety strategies must be found and employed. From an analysis of system characteristics, the nuclear power industry is proposed as an alternative analogy for safety in anaesthesia, and a novel diagrammatic approach is developed for the conceptualisation of safety goals. The nuclear power industry has spent vastly more time and money than has health care on the development of safety, and has progressed through significant safety milestones approximately three times more quickly than has anaesthesia. The greatest scope for the improvement of safety in anaesthesia lies in the appropriate re-design of medical systems and the lowering of the threshold for the reporting of incidents to include accident precursors, thus allowing the identification of dangerous systems before accidents occur.

Accidents, Occupational↗
PubMed2004

A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods.

Fifteen anaesthetists were observed while providing anaesthesia for 15 pairs of adult cardiac surgical operations, using conventional methods for one of each pair and a new drug administration system designed to reduce error for the other. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best). The new system was rated more favourably than conventional methods in terms of safety (median [range] = 8.1 [6.8-9.7] vs. 7.1 [2.6-9.3] cm; p = 0.001) and usability (8.5 [5.9-9.4] vs. 7.5 [3.2-9.8] cm; p=0.027). The new system saved preparation time both before anaesthesia (median [range] = 180 [32-480] vs. 360 [120-600] s; p=0.013) and during anaesthesia (10 [2-38] vs. 12 [10-60] s; p=0.009). Prefilled syringes for the new system increased costs by euro 23.00 per anaesthetic (p = 0.041), but this increase is likely to be offset by the potential of the new system to decrease costly iatrogenic harm by preventing drug error.

Adult↗
PubMed2004

Evidence-based strategies for preventing drug administration errors during anaesthesia.

We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.

Anesthesia, Intravenous↗
PubMed2003

A prospective clinical audit of central venous catheter use and complications in 1000 consecutive patients.

We conducted a prospective audit of central venous catheter (CVC) use in 1000 consecutive patients to better define the rates of postoperative complications (particularly vascular perforation) and the pattern of CVC and pulmonary artery catheter (PAC) usage (particularly the number of lumens inserted and utilized). Details of CVCs, complications, and the number of lumens in place and used, were recorded daily until all CVCs were removed. A total of 1546 CVCs and 223 PACs were placed in study patients. Two non-fatal perforations occurred: a perforated right atrium in a patient who received an Arrow triple-lumen CVC (previously reported), and a perforated pulmonary artery in a patient upon withdrawal of a Baxter PAC. The risk per patient of any CVC-related perforation was 0.2% (95% confidence interval (CI): 0.02% to 0.7%). The rates of CVC-related sepsis and local infection were 3% (95% CI: 2% to 4%) and 2% (95% CI: 1% to 3%) respectively. At the peak of CVC use (day 1 in the ICU) the overall number of lumens placed was significantly correlated with lumens used (r = 0.53), endorsing clinical judgement in the anticipation of the needs of the patient. The modal number of lumen uses in adults and children was four. However, in children, fewer catheters were inserted per patient than in adults (1.28 vs 1.63, P = 0.01), and placed lumens were used more intensively (P < 0.001). Data appear to justify the routine selection of a triple-lumen CVC in adult patients, but not of a quad-lumen CVC.

Adolescent↗
PubMed2002

Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error.

Ten anaesthetists were observed while providing anaesthesia for two simulated surgical procedures, twice using conventional methods and twice using a prototype of a new drug administration system designed to reduce error. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best) and comments were invited. Median safety scores were 7.7 cm (range 4.3-8.9) for the new system and 4.6 cm (1.3-8.2) for conventional methods (p = 0.009). The new system was compared favourably with conventional methods in respect of safety (p = 0.005), clinical acceptability (p = 0.008), organisation and layout (p = 0.047), and acceptability for use on patients (p = 0.005). The new system saved time in the preparation of drugs both before anaesthesia (105 vs. 346 s; p < 0.001) and during anaesthesia (20 vs. 104 s; p < 0.001). Comments facilitated development of the system and the evaluation endorsed proceeding to a clinical trial.

Anesthesiology↗
PubMed2002

Tenoxicam 20 mg or 40 mg after thoracotomy: a prospective, randomized, double-blind, placebo-controlled study.

Forty-five adults undergoing thoracotomy were randomized to receive placebo, tenoxicam 20 mg or tenoxicam 40 mg IV during chest wall closure. All patients received intraoperative fentanyl and intercostal blocks followed by morphine by patient-controlled analgesia. Patient numbers 13 to 45 also received thoracic epidural analgesia by continuous infusion of bupivacaine 0.125%, patient numbers 25 to 45 having fentanyl 2 microg/ml added to the epidural infusion. Efficacy parameters and adverse reactions were assessed over the first 24 hours postoperatively. On a 100 mm visual analogue scale, mean (SD) pain at rest (adjusted area under curve for hours 1 to 24) was 25.8 (12.5), 17.4 (14.8) and 16.5 (13.3) mm for groups receiving placebo, 20 mg and 40 mg tenoxicam, respectively (ANOVA: P<0.05). There were no significant differences between study groups postoperatively in pain on coughing, opioid consumption, blood gas measurements, nausea, vomiting, sedation, blood loss, haemoglobin or serum creatinine. One patient in each tenoxicam group reported epigastric pain, rated moderate. These data support the inclusion of tenoxicam 20 mg IV in the management of pain at rest for patients undergoing thoracotomy, but do not show additional benefit for a higher dose.

Analgesia, Patient-Controlled↗
PubMed2001

A systems approach to the reduction of medication error on the hospital ward.

AIMS: To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high-risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work. BACKGROUND: Drug administration error on the hospital ward is an ever-present problem and its occurrence is too frequent. Administering medication is probably the highest-risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse's career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour - one of the most change-resistant aspects of any system. A punitive, person-centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high-risk industries, such as aviation and nuclear power, the systems-centred approach to error reduction is routine. CONCLUSIONS: Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near-misses and system problems in addition to actual accidents, the systems-approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on-going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well-reasoned approach to its improvement.

Attitude of Health Personnel↗
PubMed2001

Touch contamination levels during anaesthetic procedures and their relationship to hand hygiene procedures: a clinical audit.

After different methods of hand preparation, volunteers rolled segments of sterile central venous catheter between their fingertips, and bacterial transfer was evaluated by standardized quantitative culture. The number of bacteria transferred differed between methods (P<0.001). Comparisons were made with the control group (no preparation at all; median, third quartile and maximum count=6.5, 24, 55). Bacterial transfer was greatly increased with wet hands (1227, 1932, 3254; P<0.001). It was reduced with a new rapid method, based on thorough drying with a combination of 10 s using a cloth towel followed by either 10 or 20 s with a hot-air towel (0, 3, 7 and 0, 4, 30, respectively; P=0.007 and 0.004, respectively). When asked to follow their personal routines, 10 consultant anaesthetists used a range of methods. Collectively, these were not significantly better than control (7.5, 15, 55; P=0.73), and neither was an air towel alone (2.5, 15, 80; P=0.176) nor the hospital's standard procedure (0, 1, 500; P=0.035). If hand preparation is needed, an adequate and validated method should be used, together with thorough hand drying.

Bacteria↗
PubMed2001

A new, safety-oriented, integrated drug administration and automated anesthesia record system.

UNLABELLED: Medication errors are an important cause of patient morbidity and mortality and excessive costs, including in anesthesia. Conventional methods of injectable drug administration in anesthesia make little use of technology to support manual checking and are idiosyncratic and relatively error prone. Similarly, conventional anesthesia records are handwritten, time-consuming to make, and often unreliable. There are automated record systems, but they do not provide support for checking drugs. Therefore, by using a multifaceted approach based on established principles of systems design and human factors psychology, we have developed a system that includes trays that promote a well-organized anesthetic workspace, color- and bar-coded labeling of syringes, and automatic visual and auditory verification of the syringe labels by computer just before each drug administration. In addition, documentation of drugs administered and a traditional anesthetic case record are generated automatically. The system has been successfully deployed for 25 mo and has been used by 35 anesthesiologists in 1148 diverse cases, including cardiopulmonary bypass procedures, heart and lung transplants, and orthopedic and otorhinolaryngologic operations. It is in daily use in a tertiary teaching center and in a private hospital. IMPLICATIONS: Traditional methods of drug administration and record keeping in anesthesia are relatively error prone. By using sound principles of systems design and human factors psychology, we have designed and deployed a system with the aim of improving patient safety by facilitating correct drug administration and accurate anesthesia record making.

Adolescent↗
PubMed2001

The frequency and nature of drug administration error during anaesthesia.

We aimed to establish the frequency and nature of drug administration error in anaesthesia (a significant subset of error in medicine) at two hospitals. Anaesthetists were asked to return a study form anonymouslyfor every anaesthetic, indicating whether or not a drug administration error or pre-error (defined as any incident with potential to become an error) had occurred. Further details were sought if the response was affirmative. From 10,806 anaesthetics, 7794 study forms were returned, representing response rates of 80% from Hospital A and 57% from Hospital B (72% overall). The frequency (95% confidence intervals) of drug administration error; of any type, per anaesthetic was 0.0075 (0.006 to 0.009), of i.v. bolus errors was 0.005 (0.0035 to 0.006) and of pre-errors was 0.004 (0.003 to 0.005), with no significant difference between hospitals. Overall, one drug administration error was reported for every 133 anaesthetics. The two largest individual categories of error involved incorrect doses (20%) and substitutions (20%) with i.v. boluses of drug. Of the i.v. bolus substitutions, 69% occurred between different pharmacological classes. One patient was aware while under muscle relaxation, and two required prolonged ventilation. In addition, 47 transient physiological effects were reported, of which five required intervention. We conclude that drug administration error during anaesthesia is considerably more frequent than previously reported.

Anesthesia↗