Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?

PURPOSE OF REVIEW: Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS: It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY: A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

[Influence of chronic, structural changes of the muscle-tendon unit on the indication and technique of rotator cuff reconstruction]

Rotator cuff lesions are common and the incidence increases with age. After tendon rupture of the rotator cuff, the muscle-tendon unit retracts, which is accompanied by muscle fatty infiltration, atrophy, and interstitial fibrosis of the musculature, thus, fundamentally changing the muscle architecture. These changes are important prognostic factors for the operative rotator cuff reconstruction outcome. Selection of the correct time point for reconstruction as well as the optimal mechanical fixation technique are decisive for successful attachment at the tendon-to-bone insertion site. Thus, knowledge of the pathophysiological processes plays an important role. The goal of this article is to establish a relationship between currently existing evidence with respect to the preoperatively existing changes of the muscle-tendon unit and the choice of the time for the operation and the operative technique.

Incorporation of a preexisting scar in the star-flap technique for nipple reconstruction

This report describes the authors' currently favored method of nipple reconstruction in cases of a pre-existing scar on the breast mound that passes through the intended site of nipple reconstruction.

Trial-to-trial size variability of motor-evoked potentials. A study using the triple stimulation technique

Motor-evoked potentials (MEPs) vary in size from one stimulus to the next. The objective of this study was to determine the cause and source of trial-to-trial MEP size variability. In two experiments involving 10 and 14 subjects, the variability of MEPs to cortical stimulation (cortical-MEPs) in abductor digiti minimi (ADM) and abductor hallucis (AH) was compared to those responses obtained using the triple stimulation technique (cortical-TST). The TST eliminates the effects of motor neuron (MN) response desynchronization and of repetitive MN discharges. Submaximal stimuli were used in both techniques. In six subjects, cortical-MEP variability was compared to that of brainstem-MEP and brainstem-TST. Variability was greater for MEPs than that for TST responses, by approximately one-third. The variability was the same for cortical- and brainstem-MEPs and was similar in ADM and AH. Variability concerned at least 10-15% of the MN pool innervating the target muscle. With the stimulation parameters used, repetitive MN discharges did not influence variability. For submaximal stimuli, approximately two-third of the observed MEP size variability is caused by the variable number of recruited alpha-MNs and approximately one-third by changing synchronization of MN discharges. The source of variability is most likely localized at the spinal segmental level.

Maxillary sinus floor elevation using the (transalveolar) osteotome technique with or without grafting material. Part I: Implant survival and patients' perception

OBJECTIVES: To analyze the survival and success rates of implants installed utilizing the (transalveolar) osteotome technique, to compare peri-implant soft tissue parameters and marginal bone levels of osteotome-installed implants with implants placed using standard surgical procedures, and to evaluate patient-centered outcomes. MATERIAL AND METHODS: During 2000 to 2005, 252 Straumann dental implants were inserted in 181 patients. The surgical technique was a modification of the original osteotome technique presented by Summers. In addition to the clinical examination, the patients were asked to give their perception of the surgical procedure, utilizing a visual analogue scale. RESULTS: The cumulative survival rate of the osteotome-installed implants after a mean follow-up time of 3.2 years, was 97.4% (95% confidence intervals: 94.4-98.8%). From the 252 implants inserted, three were lost before loading and another three were lost in the first and second year. According to residual bone height the survival was 91.3% for implant sites with < or =4 mm residual bone height, and 90% for sites with 4 mm and 5 mm, when compared with that of 100% in sites with bone height of above 5 mm. According to implant length the survival rates were 100% for 12 mm, 98.7% for 10 mm, 98.7% for 8 mm and only 47.6% for 6 mm implants. Soft tissue parameters (pocket probing depth, probing attachment level, bleeding on probing and marginal bone levels) did not yield any differences between the osteotome-installed and the conventionally placed implants. More than 90% of the patients were satisfied with the implant therapy and would undergo similar therapy again if necessary. The cost associated with implant therapy was considered to be justified. CONCLUSION: In conclusion, the osteotome technique was a reliable method for implant insertion in the posterior maxilla, especially at sites with 5 mm or more of preoperative residual bone height and a relatively flat sinus floor.