Documentation of adverse events in the department of anesthesiology: a single institution experience
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Studies indicate that voluntary reporting detects relatively few adverse events (AEs) (Ehland et al., 1999, Cooper et al., 1984). At Boston Children’s Hospital (BCH), several systems exist to document AEs. First, anesthesiologists document clinical care and AEs in the patient medical record (the Anesthesia Information Management System (AIMS)). Second, in an effort to capture AEs, the Department of Anesthesiology, Critical Care and Pain Medicine developed an internal tool, the Anesthesia System for Clinical Event Tracking (ASCENT), which is integrated into clinicians’ electronic documentation. Finally, a BCH hospital-wide reporting system, the Safety Event Reporting System (SERS), allows all employees and patients to report an AE. The goals of this study are 1) to compare the effectiveness of documentation in AIMS, ASCENT, and SERS, 2) to determine the incidence of AEs in January 2018 and June 2019, independently, and 3) compare the effectiveness of documentation AEs in ASCENT after implementation of an improved, integrated reporting system. After IRB approval, a manual chart review of 3,3204 cases requiring anesthesia in January 2018 and 3,387 cases requiring anesthesia in June 2019 was conducted. Anesthesia notes, vital signs, and administered medications documented in AIMS were reviewed to determine if an AE had occurred. Descriptions of each case were recorded, and cases with indications for AEs were verified by clinicians. Next, each AE was categorized by event type. Both ASCENT and SERS were then queried for the reported adverse events during the same time period. The total number of AEs was described using counts with the distribution of types of AEs presented using percentages. Among the 3,204 cases reviewed in January 2018, there were 569 events documented in AIMS, out of which, 39 (6.9%) were documented in ASCENT, and 2 (0.4%) in SERS. The overall rate of AEs was determined to be 1.8 events/10 cases. For June 2019, a total of 3,387 cases were reviewed for the occurrence of AEs. Among the reviewed cases, there were 396 events documented in AIMS, out of which, 106 (26.8%) were documented in the ASCENT database, and 3 (0.8%) in SERS. The overall rate of AEs was determined to be 1.2 events/10 cases. This study demonstrates that voluntary reporting of AEs may be improved if the reporting systems are better-integrated with patient medical records. In agreement with existing literature, this study also illustrates that hospital-wide reporting systems, such as SERS, fail to collect most adverse events (Levinson, 2012). To achieve comprehensive reporting of AEs, systems must be integrated into clinicians’ workflow. Education regarding the reporting systems along with technology improvements may further enhance the capture of AEs. Further investigation will be conducted to determine severity, preventability and association with anesthesia.