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An observational study of practice during transfer of patients from anaesthetic room to operating theatre.

Broom MA, Slater J, Ure DS

Department of Anaesthesia, Stobhill Hospital, Glasgow, Scotland, UK. malcolmbroom@doctors.org.uk

We observed practice during transfer of 80 patients from anaesthetic room to operating theatre, to determine the duration of apnoea and the time without monitoring during the transfer process. Median (IQR [range]) time from disconnection of the breathing system in the anaesthetic room to the first breath in theatre was 54 (44-65 [27-196]) s, and from disconnection of the pulse oximetry probe to the first reading in theatre was 90 (74-103 [44-182]) s. In four patients (5%) arterial oxygen saturation fell to 94%, with the greatest desaturation observed 11%. The transfer process may represent a window of opportunity for the occurrence of harm or the first step in a chain of events leading to harm, and is difficult to justify on patient safety grounds.

Published 18 September 2006 in Anaesthesia, 61(10): 943-5.
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