Помилки та ускладнення в практиці лікаря-анестезіолога (огляд літератури)

Автор(и)

  • О. М. Клiгуненко Днiпропетровська медична академiя МОЗ України, Україна
  • Ю. О. Площенко Дніпропетровська медична академія МОЗ України, Україна

DOI:

https://doi.org/10.25284/2519-2078.2(59).2012.107973

Ключові слова:

лікарська помилка, ускладнення, летальність, пов’язана з анестезією, захворюваність

Анотація

Обговорюються можливі причини помилок у роботі лікаря-анестезіолога і потенційних ускладнень. Проведено аналіз даних зарубіжної літератури, присвяченої причинам летальності та захворюваності пацієнтів, які пов’язані з проведенням наркозу і веденням періоперативного періоду. Наведено стандарти безпечності анестезіологічної допомоги та концепції підвищення якості і безпечності в спеціальності «анестезіологія».

Біографії авторів

О. М. Клiгуненко, Днiпропетровська медична академiя МОЗ України

Е.Н. Клигуненко

Ю. О. Площенко, Дніпропетровська медична академія МОЗ України

Ю.А. Площенко

Посилання

Молчанов И.В. (2002) Организация анестезиолого-реаниматологической помощи в РФ (пути развития). Анестезиология и реаниматология, №3, с. 817.

Петрова Н.Г., Железняк Е.С., Брацлавский В.Б. (2007) Современный взгляд на функционирование анестезиолого-реаниматологической службы (обзор литературы) // Проблемы управления здравоохранением, № 4. с. 3237.

Abeysekera A, Bergman IJ, Kluger МТ, Short TG. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60:220-7. https://doi.org/10.1111/j.1365-2044.2005.04123.x

Abildstrom H, Rentowl P, Hanning CD, Rasmussen LS, Kristensen PA, Moller JT. Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. ISPOCD group. International Study of Post-Operative Cognitive Dysfunction. ActaAnaesthesiologicaScandinavica 2000; 44: 1246-51. https://doi.org/10.1034/j.1399-6576.2000.441010.x

Adams A. The meaning of risk. In: McConachie I., ed. Anaesthesia for the High Risk Patient. London: Greenwich Medical Media, 2002: 239-47.

Adams AM, Smith AF. Risk perception and communication: recent developments and implications for anaesthesia. Anaesthesia 2001; 56: 745-55. https://doi.org/10.1046/j.1365-2044.2001.02135.x

Alan F. Merry, Jeffrey B. Cooper, Olaitan Soyannwo, Iain H. Wilson, John H. Eichhorn. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010 November; 57(11): 1027-1034. https://doi.org/10.1007/s12630-010-9381-6

Alan F. Merry, Jeffrey B. Cooper, OlaitanSoyannwo, lain H. Wilson, and John H. Eichhorn. An iterative process of global quality improvement: the International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010 November; 57(11): 1021-1026. https://doi.org/10.1007/s12630-010-9380-7

An JX, Zhang LM, Sullivan EA, Guo QL, Williams JP. Intraoperative cardiac arrest during anesthesia: a retrospective study of 218,274 anesthetics undergoing non-cardiac surgery. Chin Med J (Engl). 2011 Jan; 124(2):227-32.

Angus DC, Pereira CAP, Silva E. Epidemiology of severe sepsis around the world. EndocrMetab Immune Disord Drug Targets. 2006;6:207-12. https://doi.org/10.2174/187153006777442332

Arbous MS, Grobbee DE, van Kleef JW, de Lange JJ, Spoormans HAAJM, Touw P, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia. 2001;56:1141-53. https://doi.org/10.1046/j.1365-2044.2001.02051.x

Arbous MS, Meursing AEE, van Kleef JW, de Lange JJ, Spoormans ПН, Тоuw P, et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology. 2005; 102:257-68. https://doi.org/10.1097/00000542-200502000-00005

Aviation Accident Statistics. NTSB, 2008. Available at: http://www.ntsb.gov/aviation/Stats.htm. Accessed: October 26th, 2009.

Auroy Y, Benhamou D, Bargues L, Eccofey C, Falissard B, Mercier FJ, et al. Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002:97:1274-80. https://doi.org/10.1097/00000542-200211000-00034

Australian and New Zealand College of Anaesthetists: Safety of Anaesthesia in Australia 2000 - 2002. Editor: N Gibbs, www.anzca.edu.au/resources/books-and-publications

Australian Bureau of Statistics. Publication: Australian Demographic Statistics, Year Book Australia 2006, Catalogue # 1301.0 — 2006.

Bergman IJ, Kluger MT, Short TG. Awareness during general anaesthesia: a review of 81 cases from the Anaesthetic Incident Monitoring Study. Anaesthesia 2002; 57: 549-56. https://doi.org/10.1046/j.1365-2044.2002.02565.x

Biboulet P, Aubas P, Dubourdieu J, Rubenovitch J, Capdevila X, d'Athis F. Fatal and non fatal cardiac arrests related to anesthesia. Can J Anaesth 2001;48:326-32. https://doi.org/10.1007/bf03014958

Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, et al. Anesthesia-related cardiac arrest en children: update from the Pediatric Perioperative Cardiac Arrest Registry. AnesthAnalg. 2007;105:344-50. https://doi.org/10.1213/01.ane.0000268712.00756.dd

Blum RH, Raemer DB, Carroll JS, Sunder N, Felstein DM, Cooper JB. Crisis resource management training for an anaesthesia faculty: a new approach to continuing education. MedEduc. 2004;38(1):45-55. https://doi.org/10.1111/j.1365-2923.2004.01696.x

Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. AnesthAnalg. 2002;95(4): 1024-1030. https://doi.org/10.1213/00000539-200210000-00043

Bothner U, Georgieff M, Schwilk B. Building a large‐scale perioperative anaesthesia outcome‐tracking database: methodology, implementation, and experiences from one provider within the German quality project. British Journal of Anaesthesia 2000; 85: 271-80. https://doi.org/10.1093/bja/85.2.271

Bould MD, Crabtree NA, Naik VN. Assessment of procedural skills in anaesthesia. Br J Anaesth. 2009; 103(4):472-483. https://doi.org/10.1093/bja/aep241

Bracco D, Favre JB, Bissonnette B, et al. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. IntensiveCareMed. 2001; 27(1): 137-145. https://doi.org/10.1007/s001340000751

Braz LG, Módolo NSP, do Nascimento Jr P, Bruschi BAM, Castiglia YMM, Ganem EM, et al. Perioperative cardiac arrest: a study of 53,718 anaesthetics over 9 yr from a Brazilian teaching hospital. Br J Anaesth 2006;96:569-75. https://doi.org/10.1093/bja/ael065

Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology. 2008;109(5):905-917. https://doi.org/10.1097/aln.0b013e3181895bc1

Chan RPC, AulerJr JOC. Retrospective study of anesthetic deaths in the first 24 hours. Review of 82,641 anesthesias. Rev Bras Anestesiol 2002;52:719-27. https://doi.org/10.1590/s0034-70942002000600009

Charuluxananan S, Chinachoti T, Pulnitiporn A, Klanarong S, Rodanant O, Tanudsintum S. The Thai Anesthesia Incidents Study (THAI Study) of perioperative death: analysis of risk factors. J Med Assoc Thai. 2005;88 (suppl 7):S30-40.

Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends in anesthesia-related death and brain damage. A closed claims analysis. Anesthesiology. 2006;105:1081-6. https://doi.org/10.1097/00000542-200612000-00007

Cherian MN, Merry AF, Wilson IH: The World Health Organization and Anaesthesia. Anaesthesia. 2007, 62 (Suppl l):65-6. https://doi.org/10.1111/j.1365-2044.2007.05302.x

Consultative Council on Anaesthetic Mortality and Morbidity Ninth Report of The Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Cases reported during 2000-2002 Edited by Associate Professor Larry McNicol MBBS, FRCA, FANZCA October 2007.

Cooper JB, Gaba D: No myth: anesthesia is a model for addressing patient safety. Anesthesiology. 2002, 97:1335-7. https://doi.org/10.1097/00000542-200212000-00003

Debas HT, Gosselin R, McCord C, Thind A: Edited by Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, Surgery. Disease Control Priorities in Developing Countries. 2006 : 1245-60.

Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. British Journal of Anaesthesia 2002; 89: 409-23. https://doi.org/10.1093/bja/89.3.409

Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. British Medical Journal 2002; 324: 827-30. https://doi.org/10.1136/bmj.324.7341.827

Enright A, Merry A: The WFSA and patient safety in the perioperative setting. Can J Anaesth. 2009, 56:8-13. https://doi.org/10.1007/s12630-008-9001-x

Epstein R, F. Dexter F. Uncertainty in Knowing the operating rooms in which cases were performed has little effect on operating room allocations or efficiency // Anaesth. Analg. - 2002. - Vol. 95. - P. 1726-1730. https://doi.org/10.1097/00000539-200212000-00048

Faccenda KA, Finucane ВТ. Complications of regional anaesthesia. Incidence and prevention. Drug Safety 2001; 24: 413-42. https://doi.org/10.2165/00002018-200124060-00002

Fasting S, Gisvold SE. Serious intraoperative problems — a five-year review of 83 844 anesthetics. Canadian Journal of Anesthesia 2002; 49: 545-53. https://doi.org/10.1007/bf03017379

Fitzsimons MG, Baker KH; Not all strikes are easy to call. AnesthAnalg. 2009; 109(3) :693-694. https://doi.org/10.1213/ane.0b013e3181adc826

Fung BK, Chan MY. Incidence of oral tissue trauma after the administration of general anaesthesia. ActaAnaesthesiologicaSinica 2001; 39: 163-7.

Gaba DM, Singer SJ, SinaikoAD, Bowen JD, Ciavarelli AP. Differences in safety climate between hospital personnel and naval aviators. HumFactors. 2003;45(2):173-185. https://doi.org/10.1518/hfes.45.2.175.27238

Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320:785-8. https://doi.org/10.1136/bmj.320.7237.785

Gibbs N. Safety of Anesthesia in Australia. A review of Anaesthesia Mortality 2000-2002. 2006.

Groves RH, Holcomb BW, Smith ML: Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform 2008; 131:131-46.

Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009:360(5): 491-499. https://doi.org/10.1056/nejmsa0810119

Hansen D, Gausi SC, Merikebu M: Anaesthesia in Malawi: complications and deaths. Trop Doct. 2000, 30:146-9. https://doi.org/10.1177/004947550003000311

Helmreich R L, Merritt A C, Wilhelm J A. The evolution of Crew Resource Management training in commercial aviation. Int J Aviat Psychol; 1999;9(1): 19-32. https://doi.org/10.1207/s15327108ijap0901_2

Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. British Journal of Anaesthesia 2002; 88: 582-4. https://doi.org/10.1093/bja/88.4.582

Holte K, Kehlet H. Compensatory fluid administration for preoperative dehydration - does it improve outcome? ActaAnaesthesiologicaScandinavica 2002; 46: 1089-93. https://doi.org/10.1034/j.1399-6576.2002.460906.x

Hove LD, Steinmetz J, Christoffersen JK, Møller A, Nielsen J, Schimidt H. Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association. Anesthesiology. 2007;106:675-80. https://doi.org/10.1097/01.anes.0000264749.86145.e5

Irita K, Kawashima Y, Iwao Y, Seo N, Tsuzaki K, Morita K, et al. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui. 2004;53:320-35.

Jenkins, K. and Baker, A. B. Consent and anaesthetic risk. Anaesthesia, 58:962-984. https://doi.org/10.1046/j.1365-2044.2003.03410.x

Jeskins GD, Moore PAS, Cooper GM, Lewis M. Long-term morbidity following dural puncture in an obstetric population. International Journal of Obstetric Anesthesia 2001; 10: 17-24. https://doi.org/10.1054/ijoa.2000.0812

Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: a closed claims analysis. AnesthAnalg. 2007;104:147-53. https://doi.org/10.1213/01.ane.0000246813.04771.03

Jin F, Chung F. Minimizing perioperative adverse events in the elderly. British Journal of Anaesthesia 2001; 87: 608-24. https://doi.org/10.1093/bja/87.4.608

Kaplan HS. Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. TransfusClinBiol. 2005; 12(5):380-384. https://doi.org/10.1016/j.tracli.2005.10.003

Kawashima Y, Takahashi S, Suzuki M, Morita K, Irita K, Iwao Y, et al. Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan. ActaAnaesthesiol Scand. 2003;47:809-17. https://doi.org/10.1034/j.1399-6576.2003.00166.x

Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. CanJSurg. 2009;52(4):309-315.

Kloub R. Sore throat following tracheal intubation. Middle East Journal of Anesthesiology 2001; 16: 29-40.

Kohn L, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Institute of Medicine, National Academy Press, Washington, DC, 2000.

Kopp SL, Horlocker TT, Warner ME, Hebl JR, Vachon CA, Schroeder DR, et al. Cardiac arrest during neuraxial anesthesia: frequency and predisposing factors associated with survival. AnesthAnalg. 2005;100:855-65. https://doi.org/10.1213/01.ane.0000144066.72932.b1

Krug EG, Dahlberg LL, Mercy JA, Zwibi AB, Lozano R. World report on violence and health. Genebra: World Health Organization, 2002. p. 300-28.

Krüger A, Gillmann B, Hardt C, Döring R, Beckers SK, Rossaint R. Teaching non-technical skills for critical incidents: Crisis resource management training for medical students. Anaesthesist. 2009;58(6):582-588. https://doi.org/10.1007/s00101-009-1511-6

Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97:1609-17. https://doi.org/10.1097/00000542-200212000-00038

Laxenaire MC, Mertes PM. Anaphylaxis during anaesthesia. Results of a 2 year survey in France. British Journal of Anaesthesia 2001; 87: 549-58. https://doi.org/10.1093/bja/87.4.549

Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. OualSaf Health Care. 2004;13(Suppl 1):i85-i90. https://doi.org/10.1136/qshc.2004.010033

Leandro Gobbo Braz, Danilo Gobbo Braz, Augusto Fernandes. Mortality in anesthesia: a systematic review. Clinics 2009:64(10):999-1006. https://doi.org/10.1590/s1807-59322009001000011

Lienhart A, Auroy Y, Péquignot F, Benhamou D, Warszawski J, Bovet M, et al. Survey of anesthesia-related mortality in France. Anesthesiology 2006;105:1087-97. https://doi.org/10.1097/00000542-200612000-00008

Lindfors PM, Meretoja OA, Luukkonen RA, Elovainio MJ, Leino TJ. Suicidality among Finnish anaesthesiologists. ActaAnaesthesiol Scand. 2009;53(8): 1027-1035. https://doi.org/10.1111/j.1399-6576.2009.02014.x

Li G, Warner M, Lang B, Huang L, Sun L. Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005. Anesthesiology. 2009; 110:759-65. https://doi.org/10.1097/aln.0b013e31819b5bdc

MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J: Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health System Pharmacy. 2006;63:S5-15. https://doi.org/10.2146/ajhp060388

Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J AmCollSurg. 2006;202(5):746-752. https://doi.org/10.1016/j.jamcollsurg.2006.01.017

Melloni C. Morbidity and mortality related to anesthesia outside the operating room. Minerva Anestesiol 2005; 71(6):325-34.

Merrer J, De Jonghe B, Golliot F et al. and the French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: randomized controlled trial. Journal of the American Medical Association 2001; 286: 700-7. https://doi.org/10.1001/jama.286.6.700

Merry AF. Safety in anaesthesia: reporting incidents and learning from them. Anaesthesia. 2008, 63(4):337-39. https://doi.org/10.1111/j.1365-2044.2008.05517.x

Morray JP, Geiduschek JM, Ramamoorthy C, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000;93(1):6-14. https://doi.org/10.1097/00000542-200007000-00007

NCEPOD. Then and Now. The 2000 Report of the National Confidential Enquiry into Perioperative Deaths. London: NCEPOD, 2000.

Newland MC, Ellis SJ, Lydiatt CA, Peters KR, Tinker JH, Romberg DJ, et al. Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology. 2002;97:108-15. https://doi.org/10.1097/00000542-200207000-00016

NHS Executive. Ouality and Performance in the NHS. NHS Performance Indicators. London: NHSE, July 2000.

Ouro-Bang’na Maman AF, Tomta K, Ahouangbévi S, Chobli M: Deaths associated with anaesthesia in Togo, West Africa. Trop Doct. 2005, 35:220-2. https://doi.org/10.1258/004947505774938666

Paramesh K, Dunkley C. Lessons from the National Confidential Enquiry into Perioperative Deaths. In: McConachiel, ed. Anaesthesia for the High Risk Patient. London: Greenwich Medical Media, 2002: 41-9.

Peden MM. World Health Organization. Statistical Annex. In: Peden MM, Scurfield R, Sleer D, editors. World report on road traffic injury’ prevention. Genebra: World Health Organization, 2004. p. 189-94.

Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004-17. https://doi.org/10.1097/00000542-200204000-00031

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. HealthServRes. 2006; 41 (4Pt2):1599-1617. https://doi.org/10.1111/j.1475-6773.2006.00567.x

Redfern E, Brown R, Vincent CA. Improving communication in the emergency department. EmergMed J. 2009;26(9):658-661. https://doi.org/10.1136/emj.2008.065623

Roberts K. Organizational Change and A Culture of Safety. In: Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care, Chicago: National Patient Safety Foundation at the AMA, 1999.

Rout C. Maternal mortality and anaesthesia in Africa: a South African perspective. International Journal of Obstetric Anesthesia 2002; 11: 77-80. https://doi.org/10.1054/ijoa.2002.0944

Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian access - a systematic review. Critical Care Medicine 2002; 30: 454-60. https://doi.org/10.1097/00003246-200202000-00031

Runciman WB: Iatrogenic harm and anaesthesia in Australia. Anaesth Intensive Care. 2005, 33:297-300.

Safety of Anaesthesia. A review of anaesthesia-related mortality reporting in Australia and New Zealand 2003-2005,Editor: Neville Gibbs, MBBSl MD, FANZCA.

Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: a prospective case study. Lancet 2000; 355: 707-11. https://doi.org/10.1016/s0140-6736(99)11010-9

Sawyer RJ, Richmond MN, Hickey JD, Jarratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000; 55: 980-91. https://doi.org/10.1046/j.1365-2044.2000.01614.x

Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237): 745-749. https://doi.org/10.1136/bmj.320.7237.745

Scott RJ. Chappel v Hart: the High Court considers causation of damage from a surgeon’s negligent failure to warn. Medical Journal of Australia 2000; 172: 134-6.

Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care 2002; 6: 199-204. https://doi.org/10.1186/cc1489

Spessot GJ. Doctor, will wake up? In: Monitor. Newsletter of the New York State Society of Anesthesiologists, Inc (ed: Hill CH). 2000.

Sprung J, Warner ME, Contrens ME, Schroeder DR, Beighley CM, Wilson GA, et al. Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery. Anesthesiology. 2003;99:259-69. https://doi.org/10.1097/00000542-200308000-00006

Stainsby D, Jones H, Asher D, et al. Serious hazards of transfusion: a decade of hemovigilance in the UK. TransfusMedRev. 2006;20(4):273-282. https://doi.org/10.1016/j.tmrv.2006.05.002

Tetzlaff JE. Assessment of competence in anesthesiology. CurrOpinAnaesthesiol. 2009; September 21; Epub ahead of print. https://doi.org/10.1097/aco.0b013e3283326958

Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. MedCareforthcomingMarch 2000.Med Care. 2000;38:261-271. https://doi.org/10.1097/00005650-200003000-00003

Thompson CA. USP issues first report from medication-errors database. Am J Health Syst Pharm. 2001;58(2): 106-107.

Thompson DA, Makary MA, Dorman T, Pronovost PJ: Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients. Ann Surg. 2006;243:547-52. https://doi.org/10.1097/01.sla.0000207097.38963.3b

Toyama TM, Ranasinghe JS, Siddiqui MN, Steadman JL, Lai M. Incidence of post-dural puncture headache and epidural blood patch following dural puncture with epidural needle in 15,411 obstetric patients in a large, tertiary care teaching hospital. Anesthesiology 2002; 96: 100. https://doi.org/10.1097/00000542-200204001-00122

Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001; 322(7285) :517-519. https://doi.org/10.1136/bmj.322.7285.517

Webb RK, Currie M, Morgan CA et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesthesia and Intensive Care; 1993; 21: 520-8.

WHO: Safe Surgery Saves Lives, http://www.who.int/patientsafety/safesurgery/en/index.html

Warner ME, Fronapfel PJ, Hebl JR et al. Perioperative visual changes. Anesthesiology 2002; 96: 855-9. https://doi.org/10.1097/00000542-200204000-00012

Warner ME, Garrity JA, Mackenzie RA, Warner DO. The frequency of perioperative vision loss. Anesthesia and Analgesia 2001; 93: 1417-21. https://doi.org/10.1097/00000539-200112000-00013

Webster CS, Merry AF, Larsson L, McGrath KA, Weller J: The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001, 29:494-500.

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008, 372:139-44. https://doi.org/10.1016/s0140-6736(08)60878-8

Wu CL, Berenholtz SM, Pronovost PJ, Fleisher LA. Systematic review and analysis of postdischarge symptoms after outpatient surgery. Anesthesiology 2002; 96: 994-1003. https://doi.org/10.1097/00000542-200204000-00030

Yang H, Beattie WS: POISE results and perioperative beta-blockade. Can J Anaesth. 2008, 55:727-34. https://doi.org/10.1007/bf03016344

Zausig YA, Grube C, Boeker-Blum T, et al. Inefficacy of simulator-based training on anaesthesiologists’ non-technical skills. ActaAnaesthesiolScand. 2009;53(5):611-619. https://doi.org/10.1111/j.1399-6576.2009.01946.x

##submission.downloads##

Опубліковано

2012-06-19

Як цитувати

Клiгуненко О. М., & Площенко, Ю. О. (2012). Помилки та ускладнення в практиці лікаря-анестезіолога (огляд літератури). PAIN, ANAESTHESIA & INTENSIVE CARE, (2(59), 7–27. https://doi.org/10.25284/2519-2078.2(59).2012.107973

Номер

Розділ

Статті