Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?

Abstract

Background-Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. Objectives-To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. Methods-As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/ undesirable) and nature (process/ outcome) and control charts and logistic regression were used to analyse the data. Results-During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, diYcult intubation or allergic reaction). Conclusion-Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting.(Quality in Health Care 2000;9:203-209) Keywords: reporting system; correlation analysis; quality assessment; adverse events; anaesthesia Systematic and structured eVorts to improve the quality of anaesthetic care, based on examination of the circumstances surrounding undesired events, have a long history. In 1984 the use of reporting by practitioners of untoward events was popularised in the study of "mishaps"' and "near mishaps" 1 and it has been widely adopted since then. [2][3][4][5] In such systems very serious adverse outcomesincluding cardiac arrest, respiratory arrest, myocardial infarction, and death-are used to trigger detailed investigations of anaesthetic procedures to identify active and latent errors, 6 and thus enable appropriate corrective action to be taken. The incidence of such events has Key messages + Voluntary reporting of significant anaesthetic events is feasible and well accepted when the whole anaesthetic team is involved. + Undesirable and critical events occurring during the anaesthetic procedure are linked with risks evaluated in the ...

Critical incidents in paediatric anaesthesia: A prospective analysis over a 1 year period

“…This entity has been described in previous critical incident reporting where the potential for harm is identified before any grave harm actually occurs. [14] The early pickup 
of near misses in these 33 incidents was important as they prevented a future mishap from occurring or reaching a point of no return.…”

Les méthodes de contrôle statistique du processus permettent d’analyser et d’améliorer les soins anesthésiques

“…In a study by Boëlle and coworkers, 'undesirable' anesthesia and recovery room events were associated with development into 'critical' events with an odds ratio of 3.4-4.8. 18 Therefore, intraoperative adverse events may be used to analyze the safety and quality of the anesthetic process.…”

“…They have also been applied in health care for describing and analyzing processes that affect quality of care in healthcare organizations, 3,[26][27][28] as well as in anesthesia. 18,24,[29][30][31] Variation is expected in any process. Different conditions, patients, staff, and methods all combine randomly and contribute to variation in performance, even when the process itself remains unchanged.…”

GlideScope and Frova Introducer for Difficult Airway Management

“…Failure in airway management indeed, is a major cause of mortality and morbidity in the setting of anesthesiology and intensive care units [3, 4]. …”