Reporting adverse events during anesthesia procedures
OA Version
Citation
Abstract
Although Anesthesiology has had a long successful record in patient safety dating back to the start of the Closed Claim Project of 1984, there is still room for improvement in a field dedicated to patient safety.34 Such improvements include addressing the issue of underreporting of adverse events and errors in the healthcare systems. Boston Children’s Hospital (BCH) and their department of Anesthesiology, Critical Care and Pain Medicine is committed to ensuring a culture of patient safety by encouraging an increase in voluntary event reporting by providers. To determine the frequency of voluntary reporting and to compare the effectiveness of the reporting systems in place at BCH, three systems were used. The Anesthesia Information Management System (AIMS), was used in this study to determine the incidence of adverse events through manual chart review. The two reporting systems in place at BCH are Anesthesia System for Clinical Event Tracking (ASCENT) which is fully integrated within AIMS and the Safety Event Reporting System (SERS) which is an independent system for reporting events.
After approval from the IRB, the current retrospective study includes a manual chart review of 9,088 anesthesia cases during January 2018, June 2019, and January 2020 to determine the incidence of adverse events that were documented in AIMS. In addition, the reported events captured in both ASCENT and SERS were queried for this same period. Using statistical analysis, the event data was illustrated using total event counts and the frequency of event types reported.
It was determined that overall there was a significant increase in voluntary reports captured in ASCENT after improvements were made to the system as well as a higher frequency of reports captured in ASCENT than in SERS. Along with corresponding literature, the data supports the importance of a user-friendly and integrated reporting system in healthcare.