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Qual Saf Health Care 2005;14:e25 doi:10.1136/qshc.2002.004333
  • Crisis management

Crisis management during anaesthesia: recovering from a crisis

  1. A K Bacon1,
  2. R W Morris2,
  3. W B Runciman3,
  4. M Currie4
  1. 1Consultant Anaesthetist, St John of God Hospital, Berwick, Victoria, Australia
  2. 2Director of Research and Development, Sydney Medical Simulation Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia
  3. 3Professor and Head, Department of Anaesthesia and Intensive Care, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
  4. 4Clinical Quality Coordinator, Goulburn Base Hospital, Goulburn; and Consultant in Clinical Quality, Southern Area Health Service, New South Wales, Australia
  1. Correspondence to:
 Professor W B Runciman
 President, Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia, 5001, Australia; researchapsf.net.au
  • Accepted 12 January 2005

Abstract

Preventing harm to the patient is the priority during a crisis. After a major incident, and especially when a patient has been harmed, there are a number of matters to be addressed: the ongoing care of the patient; documentation of the incident; investigation of the root causes; completion of reports; interviews with the patient and/or the next of kin, together with apologies and expression of regret; updates and ongoing support for friends and relatives; a word of thanks to the staff involved for their assistance; formal debriefing of staff for quality assurance and possibly ongoing support and a separate debriefing for psychological purposes; ensuring that the recommendations of the root cause analysis are carried out; or, failing that, that the issues are logged on a risk register.

The extent and depth of the follow up protocol depends on what, if any, harm may have been done. This may constitute completion of an incident report; notification of an equipment failure to a federal regulatory authority; arranging consultations with a mental health professional to manage psychological sequelae (especially following an awareness episode); follow up during weeks of intensive care treatment; or, when a death has occurred, a full medico-legal and/or coronial set of procedures. A précis is appended in an action card format.

Footnotes

  • This study was coordinated by the Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia, 5001, Australia.

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