Important and urgent issues in perioperative patient safety – views of an expert panel

Important and urgent issues in perioperative patient safety – views of an expert panel

  • Issue 68

Johannes Wacker – On behalf of the Organisers
Chair, Patient Safety and Quality Committee (PSQC)

If you ever thought of patient safety as something rather theoretical, or something that is mostly detached from your everyday clinical life, a lively expert meeting during Euroanaesthesia 2016 in London could have easily proven you wrong. This summary presents the main ideas resulting from this meeting as a joint product of what this group of experienced clinicians from various clinical settings, countries, and continents, has discussed and explored to identify priorities in perioperative safety. In addition, some key references have been added for further reading.

Following an idea developed by Marcus Rall (Director, European Patient Safety Course) and Ravi Mahajan (Past Co-Chairman, PSQC), and hosted by the ESA Patient Safety and Quality Committee (PSQC), these experts were convened to an invitational, moderated, in-depth group discussion to explore the most important and most urgent current issues in perioperative patient safety. This format was influenced by the Word Café approach,[1] but the organisational details of this ninety-minute, 30-participant meeting were different from this concept. The organisers hoped to get a multifaceted picture of safety issues to be used for future educational activities and safety improvement strategies.

The first line of the discussion addressed future perspectives of perioperative patient safety: Where should we be heading in the next years? Do we have useful orientation guides – and do we actually know where we start from? Indeed, there seems to be a fundamental problem of documentation and measurement: No broad consensus about how to measure safety and quality, only a few meaningful safety and quality indicators (QI), no consistent ways of data collection. However, improving safety and quality requires that progress can be measured and monitored. The views of the participants may even underestimate important issues, because major regions like Eastern Europe were not represented at the meeting. As a step forward, the PSQC has started a project to compile quality indicators (QIs) currently used in Europe, and to develop a minimum set of QIs required in clinical practice.

The following conversation turned to the patients as the very focus of safety activities, and the victims of harm. Do we really understand what patients expect? Patient values may be key for prioritisation of safety interventions including open disclosure, and of healthcare activities in general.[2][3] Direct interaction with patients as well as qualitative research methods may help to better understand patients’ views, and to involve patients as partners in shared decision making. The impact of anaesthesia on adverse outcomes and on ‘failure to rescue’ needs rethinking and, if needed, new interpretation in view of outcomes that matter for patients.[2][4]

The discussion also zoomed in on medication safety. In view of the considerable rates of medication errors, pre-filled syringes are a solution that may promise important safety gains.[5][6] Obviously, drug and syringe labelling (‘look alikes’) and changing looks still pose significant problems. Drug shortages are alarming phenomena that have repeatedly occurred in developed countries such as the US (e.g., affecting propofol and opioids[7]); the FDA has developed a freely accessible database and an app (

The expert group also considered organisational and systems issues related to patient safety. In the operating room, distractions are becoming an important safety issue (e.g., noise,[8] multiple alarms, personal electronic devices). Discussions also included the problems of clinical reasoning and diagnostic errors;[9] fatigue and professional stress of anaesthesiologists;10 the need of further developing safety and quality education and training; and system issues like safety-II (‘learning from success’) and resilience.[11] Amalgamation of concepts based on human factors and systems thinking with clinical knowledge about patient harm may be important to integrate the approaches.

Summing up, the following priorities are only the tip of the debated patient safety iceberg. They are somewhat arbitrary, but by the nature of the meeting they provide a view that is grounded by interdisciplinary clinical expertise: 1. Documentation and measurement should reliably reflect safety and quality along the whole journey of the patient. 2. Patients should be engaged in shared decisions that include safety and patient-centred outcomes. 3. Medication safety is a practical area in particular need of current attention. 4. Many organisational and systems issues represent persistent challenges for the improvement of safety in healthcare.

Finally, future steps were considered. A web-based platform listing patient safety experts, their fields of interests, and email addresses may support networking and cooperation. The general format of the event and the view of future versions during Euroanaesthesia or ASA meetings were well received. The PSQC is working on realisation of these steps. Thanks to all participants for their contributions.

1. MacFarlane A et al. Participatory methods for research prioritization in primary care : an analysis of the Word Café approach in Ireland and the USA. Fam Pract 2016;pii: cmw104. [Epub ahead of print]
2. Porter ME et al. Standardizing patient outcomes measurement. NEJM 2016;374(6):504-6.
3. Bingener J et al. Perioperative patient-reported outcomes predict serious postoperative complications: a secondary analysis of the COST trial. J of Gastrointest Surg 2015;19(1):65-71; discussion 71.
4. Loftus RW. Infection control in the operating room: is it more than a clean dish? Curr Opinion Anaesthesiol 2016;29(2):192-7.
5. Orser BA et al. Perioperative medication errors: Building safer systems. Anesthesiology 2016;124(1):1-3.
6. Yang Y et al. A human factors engineering study of the medication delivery process during an anesthetic: Self-filled syringes versus prefilled syringes. Anesthesiology 2016;124(4):795-803.
7. De Oliveira GS et al. Drug shortages in perioperative medicine: past, present or future? Anesth Analg 2015;121(2):259-61.
8. Kurmann A et al. Adverse effect of noise in the operating theatre on surgical-site infection. Brit J Surg 2011;98(7):1021-5.
9. Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.
10. Gurman GM et al. Professional stress in anesthesiology: a review. J Clin Monit Comput 2012;26(4):329-35.
11. Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opinion Anaesthesiol 2015;28(6):735-9.