A nationwide system to collect adverse events from anesthesia

A nationwide system to collect adverse events from anesthesiaA guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

Anesthesiologists have been at the forefront of the patient safety movement. Over the past 25 years, anesthesia-related deaths have declined from two deaths per 10,000 anesthetics administered to one death per 200,000 to 300,000 anesthetics administered, due to improvements in patient safety and innovative research that have paved the way for modern medical procedures.

In an effort to continue the patient safety movement, the Anesthesia Quality Institute has activated the first nationwide system to collect individual adverse events from anesthesia, pain management and perioperative care. The system, known as the Anesthesia Incident Reporting System (AIRS), will collect information on unintended events and near misses during anesthesia cases.

Any anesthesia provider is encouraged to report any unintended event including those related to anaphylactic reactions, device malfunctions, medication side effects, unusual vascular or neurologic injuries and complications of electronic health care records. All reports are confidential, and protected from legal discovery by the AQI’s status as a Patient Safety Organization. Reports are entered into AIRS using a simple web-based interface, and take less than 5 minutes to complete. The AIRS system allows for reports to be forwarded to practice or hospital quality and risk officers, as needed, to simultaneously meet local reporting requirements.

The AQI will use AIRS data in two ways:

  1. Interesting and unique cases will be fictionalized, and used for educational case presentations and learning discussions. The first monthly case publication concerned a patient with unexpected life-threatening hemorrhage following a routine spine operation. Diagnostic strategies and recommendations for therapy were included.
  2. The entire AIRS Registry will be used to identify emerging trends in anesthesia patient safety, including reactions to new medications, complications of new surgical procedures, and failure of medical devices or monitors.

Richard P. Dutton is the Executive Director of the Anesthesia Quality Institute. 

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