Incidence and Classification of Nonroutine Events during Anesthesia Care

Conclusions This study describes characteristics of intraoperative nonroutine events in a cohort of cases at three academic hospitals. Nonroutine event –containing cases were commonly associated with patient impact and injury. Thus, nonroutine event monitoring in conjunction with traditional error reporting may enhance our understanding of potential intraoperative failure modes to guide prospective safety interventions.Editor ’s PerspectiveWhat We Already Know about This TopicA nonroutine event is defined as any aspect of clinical care perceived by clinicians or observers as a deviation from optimal care for a patient in a clinical situationNonroutine events are frequent and associated with increased clinician workload and patient physiologic disturbancesWhat This Article Tells Us That Is NewVideo recordings of 511 cases from 1998 to 2004 were viewed to identify nonroutine events, which occurred in 22% of cases, and some cases had multiple eventsOne in fifteen patients had events associated with some degree of patient injuryThe most common contributory factors were related to provider, patient, or teaching/supervision

Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research