A Facilitated Survey Instrument Captures Significantly More Anesthesia Events Than Does Traditional Voluntary Event Reporting

Abstract

An active surveillance tool using the NRE construct identified a large number of clinical cases with potential patient safety concerns. This approach may be a useful complement to more traditional QA methods of self-reporting.

Significant Physiological Disturbances Associated With Non-Routine Event Containing and Routine Anesthesia Cases

“…NRE-containing cases were identified using a postcase anesthesia provider survey and subsequently confirmed by clinician expert video review. 3,17 Thus, in this study, all NREs were reported immediately after the case by the clinician caring for that patient. For example, a case involving a patient with a normal airway anatomy would be classified as containing an NRE if, during the endotracheal intubation, the tube was inadvertently placed in the esophagus rather than the trachea, even if this was rapidly recognized and corrected.…”

“…In previous studies, we demonstrated that anesthesia NRE were frequent (occurring in perhaps 35% of cases), could be captured prospectively either via direct observation 4 or by provider interview in the post-anesthesia recovery room, 3 and were associated with known performance-shaping factors like clinician workload. 9,10 The NRE construct has been extended to studies of the entire surgical team 10 and to nurses in the intensive care unit.…”

“…3,5 Thus, although NREs include ''near misses'' 6 and ''critical incidents,'' 7,8 they also encompass events that may not have an immediately obvious link to adverse outcomes but still could provide early clues to important latent conditions in health-care systems. For example, the failure of the results of routine preoperative laboratory test values to be available just before surgery would not generally be considered by most clinicians to be a ''near miss.''…”

Learning from Adverse Events and Near Misses

“…2 Oken and colleagues compared the sensitivity for this type of proactive open-ended questioning to online self-reporting. 3 Safety-compromising events were identified in 30% of cases with prospective questioning, compared to 1.9% with self-reporting.…”

Leadership and teamwork in anesthesia – Making use of human factors to improve clinical performance

“…This precludes oversimplified rules for leadership and team co-ordination. Unexpected events are common even in routine anesthesia cases 47,48 and challenge teams to shift rapidly between co-ordination forms. Intraoperative cardiac arrest is a rare event and would usually trigger a cardiopulmonary resuscitation (CPR) alarm.…”