The purpose of this study was to assess the validity of a multisite anesthesia voluntary adverse event reporting process. A data validation methodology was used through medical chart review on live records at 3 facilities (N = 600). The per-item aggregated error rate among all 42 data items was 0.3%: 0.1% for quality indicators, 1.3% for demographic/status variables, and 1.7% for administrative items. The per-patient error rate among all 42 data items was 6.3%: 3.0% for quality indicators, 1.7% for demographic/status variables, and 3.0% for administrative items. Trends such as better accuracy for more serious events continue, but observed error rates were lower than those found in previous surveys—an indication that, while further study is needed, nonpunitive voluntary reporting may reduce errors in anesthesia care.
CooperJBNewbowerRSKitzRJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60:34-42.
2.
KumarVBarcellosWAMehtaMPCarterJG. An analysis of critical incidents in a teaching department for quality assurance: a survey of mishaps during anaesthesia. Anaesthesia. 1988;43:883-886.
3.
BishopMJSoudersJEPetersonCMHendersenWGDominoKB. Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Anesth Analg. 2008;107:1924-1935.
4.
KohnLTCorriganJDonaldsonMS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
5.
CohenMMDuncanPGPopeWD. The Canadian four-centre study of anaesthetic outcomes: II. Can outcomes be used to assess the quality of anaesthesia care?Can J Anaesth. 1992;39(5, pt 1):430-439.
6.
ShortTGO’ReganALewJOhTE. Critical incident reporting in an anaesthetic department quality assurance programme. Anaesthesia. 1993;48:3-7.
7.
WebbRKCurrieMMorganCA. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:520-528.
8.
LiGWarnerMLangBHHuangLSunLS. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology. 2009;110:759-765.
9.
JayasuriyaJPAnandacivaS. Compliance with an incident report scheme in anaesthesia. Anaesthesia. 1995;50: 846-849.
10.
LightdaleJRMahoneyLBFredetteMEValimCWongSDiNardoJA. Nurse reports of adverse events during sedation procedures at a pediatric hospital. J Perianesth Nurs. 2009;24:300-306.
11.
OkenARasmussenMDSlagleJM. A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. Anesthesiology. 2007;107:909-922.
12.
VigodaMMGencorelliFLubarskyDA. Changing medical group behaviors: increasing the rate of documentation of quality assurance events using an anesthesia information system. Anesth Analg. 2006;103:390-395.
13.
NastPAAvidanMHarrisCB. Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit. J Thorac Cardiovasc Surg. 2005;130:1137.
14.
BensonMJungerAFuchsC. Using an anesthesia information management system to prove a deficit in voluntary reporting of adverse events in a quality assurance program. J Clin Monit Comput. 2000;16:211-217.
15.
BoëllePYGarnerinPSicardJFClergueFBonnetF. Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?Qual Health Care. 2000;9:203-209.
16.
O’NeilACPetersonLACookFEBatesDWLeeTHBrennanTA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370-376.
17.
Plews-OganMLNadkarniMMForrenS. Patient safety in the ambulatory setting. A clinician-based approach. J Gen Intern Med. 2004;19:719-725.
18.
CooperJB. Is voluntary reporting of critical events effective for quality assurance?Anesthesiology. 1996;85:961-964.
19.
McDonaldTBHelmchenLASmithKM. Responding to patient safety incidents: the “seven pillars.”Qual Saf Health Care. 2010;19:e11.
20.
SanbornKVCastroJKurodaMThysDM. Detection of intraoperative incidents by electronic scanning of computerized anesthesia records. Comparison with voluntary reporting. Anesthesiology. 1996;85:977-987.
21.
LagasseRSSteinbergESKatzRISaubermannAJ. Defining quality of perioperative care by statistical process control of adverse outcomes. Anesthesiology. 1995;82: 1181-1188.
22.
StonemetzJ. Anesthesia information management systems and sharing your patient data: a resource for potential users. http://www.aqihq.org/introduction.pdf. Accessed October 1, 2011.
TrentmanTLMuellerJTRuskinKJDoyleCANobleBN. Adoption of anesthesia information management systems by US anesthesiologists. J Clin Monit Comput. 2011;25: 129-135.
25.
LeapeLL. Reporting of adverse events. N Engl J Med. 2002;347:1633-1638.
26.
HaynesABWeiserTGBerryWR. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499.
27.
ClancyCMTornbergDN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22:214-217.
28.
GaleEAM. The Hawthorne studies—a fable for our times?QJM. 2004;97:439-449.
29.
BlythCR. Approximate binomial confidence limits. J Am Stat Assoc. 1986;81:843-855.
30.
LeapeLL. Reporting of medical errors: time for a reality check. Qual Health Care. 2000;9:144-145.
