PMID- 28858900
OWN - NLM
STAT- MEDLINE
DCOM- 20180102
LR  - 20180430
IS  - 1526-7598 (Electronic)
IS  - 0003-2999 (Linking)
VI  - 126
IP  - 1
DP  - 2018 Jan
TI  - Trends in the Prevalence of Intraoperative Adverse Events at Two Academic 
      Hospitals After Implementation of a Mandatory Reporting System.
PG  - 134-140
LID - 10.1213/ANE.0000000000002447 [doi]
AB  - 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.
FAU - Wanderer, Jonathan P
AU  - Wanderer JP
AD  - From the Vanderbilt University Medical Center, Nashville, Tennessee.
FAU - Gratch, David M
AU  - Gratch DM
AD  - Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, 
      Pennsylvania.
FAU - Jacques, Paul St
AU  - Jacques PS
AD  - From the Vanderbilt University Medical Center, Nashville, Tennessee.
FAU - Rodriquez, Luis I
AU  - Rodriquez LI
AD  - University of Miami, Miller School of Medicine, Miami, Florida.
FAU - Epstein, Richard H
AU  - Epstein RH
AD  - University of Miami, Miller School of Medicine, Miami, Florida.
LA  - eng
PT  - Journal Article
PT  - Multicenter Study
PL  - United States
TA  - Anesth Analg
JT  - Anesthesia and analgesia
JID - 1310650
SB  - IM
MH  - Hospitals, University/*trends
MH  - Humans
MH  - Intraoperative Complications/*epidemiology/prevention & control
MH  - *Mandatory Reporting
MH  - Medical Errors/prevention & control/*trends
MH  - Prevalence
EDAT- 2017/09/01 06:00
MHDA- 2018/01/03 06:00
CRDT- 2017/09/01 06:00
PHST- 2017/09/01 06:00 [pubmed]
PHST- 2018/01/03 06:00 [medline]
PHST- 2017/09/01 06:00 [entrez]
AID - 10.1213/ANE.0000000000002447 [doi]
PST - ppublish
SO  - Anesth Analg. 2018 Jan;126(1):134-140. doi: 10.1213/ANE.0000000000002447.