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

Wanderer, Jonathan, P., MD, MPhil*; Gratch, David, M., DO; Jacques, Paul, St., MD*; Rodriquez, Luis, I., MD; Epstein, Richard, H., MD, CPHIMS

doi: 10.1213/ANE.0000000000002447
Patient Safety: Original Clinical Research Report

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.

Published ahead of print August 30, 2017.

From the *Vanderbilt University Medical Center, Nashville, Tennessee

Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania

University of Miami, Miller School of Medicine, Miami, Florida.

Published ahead of print August 30, 2017.

Accepted for publication July 27, 2017.

Funding: Departmental.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

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This study was presented in part as an abstract at the 2016 Annual Meeting of the Society for Technology in Anesthesia, January 6-9, Palm Beach, Florida.

Institutional review board contact information: Approved September 3, 2015, Jacquie Wright, Office of Human Research, Thomas Jefferson University. Institutional review board exemption granted, Human Research Protection Program, Vanderbilt University.

Reprints will not be available from the authors.

Address correspondence to Jonathan P. Wanderer, MD, MPhil, Vanderbilt University Medical Center, 1301 Medical Center Dr, the Vanderbilt Clinic, Suite 4648, Nashville, TN 37232-5614. Address e-mail to

© 2018 International Anesthesia Research Society
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