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Perioperative quality of care and patient safety

Koers, L.

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Citation for published version (APA):Koers, L. (2019). Perioperative quality of care and patient safety.

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Download date: 29 Jun 2020

Lena Koers

Perioperative Quality of Care and Patient Safety

Perioperative Quality of Care and Patient Safety

Lena Koers

Perioperative Quality of Care and Patient Safety

Lena Koers

Perioperative Quality of Care and Patient Safety

ColofonQuality of Care and Patient Safety in Perioperative CareAcademic thesis, University of Amsterdam, Amsterdam, the Netherlands

ISBN 9789463238069

Author: Lena KoersCover: “the rat study: a Tripod Beta analysis of an electrocution fatality” design and layout: Willem Thijs and Lena KoersImages: Willem Thijs, https://nomnomratsel.tumblr.com/Printing and layout: Gildeprint, Enschede, The Netherlands

© Lena Koers 2019All rights reserved. No part of this thesis may be reproduced, stored or transmitted in any form or by any means, without written permission of the author.

Perioperative Quality of Care and Patient Safety

ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad van doctoraan de Universiteit van Amsterdamop gezag van de Rector Magnificus

prof. dr. ir. K.I.J. Maexten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Agnietenkapelop woensdag 20 november 2019, te 10.00

door

Lena Koersgeboren te Nijmegen

Promotiecommissie

Promotores: Prof. dr. B. Preckel AMC-UvA Prof dr. dr. M.W. Hollmann AMC-UvA

Copromotores: Dr. S. Eberl AMC-UvA Dr. J. Hermanides AMC-UvA

Overige leden: Prof. dr. P Fockens AMC-UvA Prof. dr. S.E. Geerlings AMC-UvA prof. dr. M.P. Schijven AMC-UvA Prof. dr. S.A. Loer Vrije Universiteit Amsterdam Prof. dr. A.P. Wolff Rijksuniversiteit Groningen Dr. D.A. Dongelmans AMC-UvA

Faculteit der Geneeskunde

Table of Contents

Chapter 1 General introduction 7

Part I General aspects of safety and quality improvement in perioperative care

Chapter 2 Safety in the operating theatre 15Chapter 3 Safety culture 29Chapter 4 Guidelines and best practice management 39

European implementation of the ESC and ESA guidelines on non-cardiac surgery: cardiovascular assessment and management.

Chapter 5 Recommendations from the guideline-but how to do it? 51The surgical airway in the paediatric can’t intubate, can’t oxygenate crisis.

Chapter 6 Patient safety audit 65Safety of moderate-to-deep sedation performed by sedation practitioners – a national prospective observational study.

Chapter 7 The impact of performance improvement programmes on patient outcome

81

Impact of a targeted performance improvement programme on outcome in haemodynamically unstable patients with a pelvic fracture.

Part II: Assessments, tools and interventions to enhance safety and quality of perioperative care

Chapter 8 Introduction to cognitive aids, creating and implementing cognitive aids

99

Chapter 9 The use of cognitive aids during critical events 109The management of anaphylactic shock during percutaneous drainage of a hydatid cyst.

Chapter 10 Cognitive aids for deteriorating surgical patients 113Chapter 11 Choice of sedatives to improve quality and safety of procedural

sedation and analgesia127

Esketamine versus Alfentanil as an adjunct to Propofol sedation for ERCP: effectiveness and safety. A randomised controlled multicentre trial.

Chapter 12 Reducing medication error 139A standardised user applied drug label for high-risk anaesthetic drugs.

Chapter 13 General Discussion 149Chapter 14 Summaries in Dutch and English 155Appendices PhD Portfolio 161

List of Publications 163Dankwoord 165About the Author 167