Trends in the Prevalence of Intraoperative Adverse Events at Two Academic Hospitals After Implementation of a Mandatory Reporting System.

BACKGROUND: Anesthesia information management systems (AIMSs) have been effectively used to improve quality in anesthesia care, and have enabled the development of mandatory quality assurance (QA) reporting systems for adverse events (AEs). While this approach has been shown to increase event reporting over time, the long-term effect of such a system on quality is unknown. We investigated the trends in AE reporting over time after implementing AIMS-based mandatory reporting systems at 2 academic medical centers. METHODS: At Thomas Jefferson University Hospital, AEs were retrieved after implementation of a mandatory QA process in 2013. These AEs were categorized as preventable and unpreventable. The rates of overall preventable and unpreventable AEs were analyzed over time. At Vanderbilt University Medical Center, the rates of AEs were analyzed after establishing a mandatory QA process in 2002. Data were binned by quarter, and trends over time were analyzed using the Mann-Kendall test. RESULTS: At Thomas Jefferson University Hospital, over a period of 2 years after implementation of a mandatory QA process, the documented AE rate decreased from 1.23% to 0.64% (P < .0001). This decrease occurred primarily in the group of preventable AEs, which declined from 1.01% to 0.52% (P = .014). The rate of unpreventable AEs was unchanged, from 0.22% to 0.12% (P = .12). At Vanderbilt University Medical Center, over a 7-year period after implementation, the AE rate decreased from 4.20% to 1.36% (P < .0001). CONCLUSIONS: After implementation of a mandatory QA process at 2 academic medical centers, documented AE rates decreased significantly. The decrease observed in preventable AEs, with unchanged rates of unpreventable AEs, demonstrates that mandatory reporting of intraoperative AEs was followed by a reduction in preventable intraoperative AEs. If our findings are replicated at other institutions and are shown to have a stronger trend compared with institutions where the implementation was not conducted, or there was a change from preimplementation trends, adding mandatory perioperative outcomes reporting in the AIMS may represent a valuable method to improve the overall safety of anesthesia.

Prophylactic Antibiotic Management of Surgical Patients Noted as "Allergic" to Penicillin at Two Academic Hospitals.

We studied prophylactic antibiotics administered at 2 academic medical centers during a 6-year period where a cephalosporin was indicated but an "allergy" to penicillin was noted. Another drug (typically vancomycin or clindamycin) was substituted approximately 80% of the time; this occurred frequently even when symptoms unrelated to acute hypersensitivity were listed. In >50% of cases, the reaction was either omitted or vague (e.g., simply "rash"). Given the estimated 1% cross-reactivity between penicillins and cephalosporins with similar R1 side chains, many of these patients could have received either the prescribed cephalosporin or another cephalosporin with a different R1 side chain.

An analysis of risk factors for patient complaints about ambulatory anesthesiology care.

BACKGROUND: Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS: We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS: A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04-2.08), 0.22 (95% CI, 0.07-0.62), and 1.27 (95% CI, 1.10-1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47-0.92), 0.67 (95% CI, 0.47-0.95), 1.18 (95% CI, 1.01-1.38), and 1.96 (95% CI, 1.17-3.29), respectively. CONCLUSIONS: There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

BACKGROUND: In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS: Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS: Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10(-5) (95% confidence interval [CI], 4.5 × 10(-5) to 23.1 × 10(-5)). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10(-5)). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS: In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Evaluation of a hands-free wireless communication device in the perioperative environment.

The objective of this study was to evaluate the efficiency and reliability of a hands-free voice over Internet protocol (VOIP) communication system in the perioperative environment. Two surveys were administered to anesthesiologists and operating room (OR) nurses working at an academic medical center. Providers were queried by alphanumeric pages or VOIP queries during OR work shifts to measure communication response times. Providers, responding to the query, were asked to verbally complete a system performance survey to capture information regarding their workload and work environment at the time of the query. A user feedback survey was independently administered in writing to a convenience sample of OR providers to obtain information regarding provider communication preferences, concerns, and recommendations. OR providers responded to communication queries four times faster when using VOIP compared to alphanumeric pagers. Providers found VOIP to be much less reliable than conventional pager-telephone systems. Dead spots in the 802.11b network and errors in speaker recognition were frequently cited as sources of system failures. Providers also expressed concern in maintaining confidentiality of patient data or other clinical data communicated using this system. The results of this study suggest that VOIP is still a developing technology but one that is currently viable in the clinical setting. The technology can be used efficiently and securely in health care if users are given the proper training its functions and capabilities.