Klinisches Risikomanagement

BACKGROUND: The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety. MATERIALS AND METHODS: A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented. RESULTS: The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period. CONCLUSIONS: Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).     

Strukturiertes Team-Feedback bei der Reanimation

Background

The guidelines for cardiopulmonary resuscitation (CPR) recommend algorithms for basic and advanced life support that define timepoints as well as procedures and medications. During resuscitation, it might be difficult to follow these algorithms exactly and non-compliance is often not recognized by the response team itself. We investigated the effects of implementation of a structured team feedback reporting system in a prehospital emergency medical service (EMS) on the adherence to guideline recommendations.

Methods

In a two-tiered physician staffed EMS serving approximately 251,800 inhabitants, a structured team feedback reporting system was implemented. Feedback was given by an external review of the medical report and internal storage of ECG/defibrillator measuring key data including time-to-defibrillation and average dosage of epinephrine. A detailed structured report form with individual results was sent to each team member within 2 days after each resuscitation call. Data from implementation between 1 February 2014 and 30 April 2015 were evaluated and time-to-defibrillation and average epinephrine dosage was compared with guideline recommendations for the first and last 3-month period using the U-test; results provided as median (25/75?% percentiles).

Results

A total of 283 cases were included; return of spontaneous circulation (ROSC) was achieved in 119 patients (42.1?%). Hands-off time: 11.9?% (8.7/16?%); longest interruption of CPR: 22 s (14/32 s); 12-channel ECG after ROSC: n?=?72 (60.5?%). Results of first vs. last period: time to first defibrillation (n?=?17): 149 s (81/249 s) vs. 107 s (85/191 s, p?=?0.96); time 1st–2nd defibrillation (n?=?13): 222 s (129/536 s) vs. 159 s (134/231 s, p?=?0.72); time 2nd–3rd defibrillation (n?=?11): 179 s (123/441 s) vs. 134 s (110/216 s, p?=?0.42). Dosage of epinephrine (n?=?81): 0.92 mg/5 min (0.61/1.31 mg/5 min) vs. 1.19 mg/5 min (0.93/1.8 mg)/5 min, p?=?0.02).

Conclusions

Structured team feedback is able to show the adherence to guidelines in resuscitation on the scene. The time to first defibrillation was mostly in accordance with guidelines, the time to third defibrillation exceeded the recommended 6 min during both periods. The correct average dose of epinephrine significantly improved following implementation of structured feedback.

     

Risikomanagement besonderer Infektionssituationen

Trauma und Berufskrankheit - Die WHO schätz die Gefahr einer Influenzapandemie sehr hoch ein. Durch die Globalisierung gelangen aber auch andere seuchengefährliche Krankheiten wie SARS...     

Seminom klinisches Stadium I

Background

The therapy of stage I seminoma is under constant change. While surveillance, adjuvant radiotherapy and adjuvant chemotherapy were seen as equal therapeutic alternatives up to a few years ago, recently published studies make it necessary to adopt a more differentiated approach.

Discussion

In this review, recent data on the long-term effects of adjuvant radiotherapy and chemotherapy, the question of risk stratification as well as the advantages and limitations of a surveillance strategy are discussed.     

Risikomanagement besonderer Infektionssituationen

The WHO considers that there is considerable danger of an influenza pandemic. One result of globalisation is that other highly contagious infectious diseases, such as SARS or Ebola, which are potentially endemic, can also be brought into Germany. Bioterorrism must also be considered. As well as all other medical disciplines, hospital surgical departments must be armed against this now. National pandemic planning will be taken as an example to illustrate the planning needed in hospitals to prepare for emergencies arising from infections in such specific situations.     

Klinisches Risikomanagement in der Arztpraxis

Journal für Ästhetische Chirurgie -     

Risikomanagement und Patientensicherheit

Risk management and patient safety are of indisputable importance for the quality of health care. At the same time they confront all professional groups in the health system with high demands. The Action Alliance for Patient Safety inc. wants to demonstrate ways in which measures for avoiding errors and improving safety can reach the healthcare practice. Interdisciplinary cooperation and the availability of mutually developed materials are the maxims of the work of the society.     

Präklinisches Management des Abdominaltraumas

Accounting for only 2–5% of all accidental injuries, isolated trauma to the abdominal cavity is a rare occurrence. On the other hand, concomitant abdominal injuries must be anticipated in up to 53% of polytraumatized patients. In contrast to open abdominal injuries, the considerably more frequent blunt traumas cannot be directly visualized. This explains the sizable portion of injuries overlooked at the accident site. Direct indicators include the accident mechanism, signs of bruising, shoulder pain, and evidence for rib fractures of the lower half of the thorax. In the presence of a decline in blood pressure and symptoms of shock but no apparent bleeding, consideration should be given to an intra-abdominal hemorrhage. Prehospital sonography performed with a portable ultrasound device could improve future diagnostics. In the case of circulatory instability, priority is given to transporting the patient to the nearest suitable hospital. The emergency physician should decide on the receiving hospital according to the injury severity. Identification of leading symptoms and adherence to a diagnostic as well as therapeutic algorithm will aid the emergency physician in adapting an approach to the symptoms during the phase of prehospital care. Alarming the shock room team in advance will optimize management in the receiving hospital.     

Risikomanagement und Human Factor in der Akutmedizin

Background

Emergency medicine poses a high risk environment and because of its complexity contains an abundance of error sources. Risk management is system-oriented and preventive. It begins before incidents occur and involves a systematic and subsequent elimination of system deficits. The working environment (emergency) medicine must be geared to the actual and real actors. Errors by humans are inherent but frequently are not caused by deficits in knowledge or skills but other factors exist that hinder or prohibit the deployment of existing and current skills.

Method

Literature search and evaluation of relevant articles concerning the human factor.

Results

The human factors approach aims at optimizing the interaction of humans, team and organization as well as the interface of human and (medical) technology.

Conclusion

The working environment has to be geared to the human aspects, use certain precautions to prevent errors and to provide the general conditions for optimal achievements.     

Präklinisches Management des Polytraumas

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suiting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.     

Präklinisches Management bei Explosionsverletzungen

Injuries caused by an explosion are rarely encountered in preclinical emergency medical care in the German-speaking region. Due to the increasing globalization of terrorism, however, a bomb attack must also be anticipated at any time in Germany. Explosion injuries are classified into four categories based on their injury mechanisms: primary, secondary, tertiary, and quaternary explosion injuries. The harmful noxae include an overpressure surge, splinters and fragments, injuries caused by a fall or impact trauma as well as fire and hot fumes. The severity of the injury depends on diverse factors. Decisive features are the proximity to the explosion site, the amount of explosives, and the location of the detonation. Terrorist attacks entail considerable risk potential for rescue workers as a result of dirty bombs, duds, and additional detonations. It is imperative to allow for this situation in tactical considerations. By virtue of the large number of injury victims, the specific injury patterns, and the safety status, management of these kinds of rescue missions must be considered highly challenging.     

Die Mitralstenose,klinisches Bild und chirurgische Behandlung

Ohne Zusammenfassung     

Seminom klinisches Stadium I: immer noch Fragen offen

Regarding the spectrum of clinical features of testicular germ cell tumours, seminoma clinical stage I (CSI) represents the most frequent clinical situation. According to current guidelines, four strategies are feasible for managing this stage: surveillance, para-aortal radiotherapy with 20 Gy, two courses of carboplatin (400 mg/m² or AUC7), or a single course of carboplatin AUC7. Internationally published trials have revealed relapse rates of 15–20% with surveillance and 1.5–5% with adjuvant strategies. Basically, all relapses are curable. The German National Seminoma Registry study (NSR study) aims to analyse the patterns of care at the national level regarding use of the four management strategies for seminoma CSI. In addition, factors associated with therapeutic decision making will be evaluated. The second aim of the study is to find out whether the excellent results regarding relapse rates and overall survival in seminoma CSI as reported internationally can be reproduced. All urologic surgeons caring for seminoma patients in Germany are strongly encouraged to enter their patients into this national study of patterns of care.     

55. Prognose,klinisches Erscheinungsbild und Therapie der Thoraxkontusion

Zusammenfassung Aus einer Analyse von 195 konsekutiven schweren Thorax-kontusionen (Chirurgische Universitätsklinik Heidelberg 1966–1970) ergab sich eine globale Letalität von 28%. Unter Berücksichtigung von Alter, Art der Verletzung und Ausmaß der Ventilationsstörung betrug die Letalität unter Respiratortherapie 48%, in Fällen mit O₂ Insufflation unter Spontanatmung 8%. Der tödliche Ausgang eines Thoraxtraumas wird vielfach durch Begleitkomplikationen verursacht und ist nicht ausschließlich vom Schweregrad des pulmonalen Traumas abhängig. Blutgasanalysen, atemmechanische Funktionswerte, Röntgenbefund und hämodynamische Situation gestatten unmittelbar nach einem Thoraxtrauma keine zuverlässigen Rückschlüsse auf die Prognose. Deshalb ist jedes schwere Thoraxtrauma unverzüglich einer wirksamen Intensivtherapie zuzuführen. Dabei kommt einer gewissenhaften Kontrolle der Flüssigkeitsverluste und der Einhaltung einer negativen Flüssigkeitsbilanz besondere Bedeutung zu.

---

Clinical features and therapy in case of thoracic contusion

Summary An analysis of 195 consecutive cases of severe contusions of the thorax treated at the Surgical University Clinic, Heidelberg, between 1966 and 1970, revealed an overall mortality rate of 28%. When taking into account the age of the patients, the type of injury and the extent of the breakdown of ventilation, the mortality rate in patients receiving respirator therapy was 48%, while in the cases with O₂ insufflation and spontaneous respiration it was 8%. The fatal outcome of a thorax injury is often caused by accompanying complications and is not exclusively dependent on the degree of severity of the pulmonary trauma. Blood gas analysis, pulmonary-mechanical function tests, X-ray findings and haemodynamic studies do not permit reliable conclusions with regard to the prognosis immediately after the injury to the thorax. One has therefore to commence immediately an effective, intensive therapy in every patient with a severe injury to the thorax. In such cases very careful control of fluid losses and the maintenance of a negative fluid balance are of special importance.