System to report adverse events in anesthesia is improving practice

  • Theory, Practice, and Results of the U.S. and Australia/New Zealand Incident Reporting Systems
  • Monday, 3:30-4:30 p.m.
  • McCormick Place West, W471

A system of confidentially reporting adverse events in anesthesia has been in use for several years in the United States, Australia and New Zealand. A review of that reporting system and how it can improve practice will be presented during a Monday education session.

“We have worked over the last five years on joint methods to use anesthesia incidence reporting to improve patient care. The idea is that we can’t fix what we don’t know about. By asking our partners in anesthesiology to enter cases of harm or cases where harm almost occurred, also known as near-misses, we can learn from those and inform the anesthesia community about ways to prevent those from happening to patients,” said Patrick J. Guffey, M.D., Chair of the Anesthesia Quality Institute (AQI) Anesthesia Incident Reporting System.

Theory, Practice, and Results of the U.S. and Australia/New Zealand Incident Reporting Systems” will feature Dr. Guffey and Alan Merry, M.B., Ch.B., Chair of the Board of the NZ Health Quality and Safety Commission.

The Australia/New Zealand system was established 10 years ago, and the U.S. system five years ago. Incident reports are collected by the AQI and case reports are published on the AQI website.

“We hold this data in high confidence in accordance with the Patient Safety and Quality Improvement Act. People should be able to feel they can report in confidence and know that their personal information will not be disclosed,” said Dr. Guffey, Associate Professor at the University of Colorado and Associate Chief Medical Information Officer at Children’s Hospital Colorado, Aurora.

“To continue to move to a culture of zero harm, we need to be able to aggregate events across a large set of practices,” he said. “A medication, a piece of anesthesia equipment or a new therapy or modality that has had incremental harm associated with it at various institutions across the country can be detected much faster with a system like this than if it had to occur multiple times locally.”

Monday’s session will feature a demonstration of the U.S. and Australian/New Zealand reporting systems, as well as results.

“We want to move anesthesia care to high reliability. The strategy to do that is to take best practices in quality, such as incident reporting, and make them reliable through informatic solutions such as our national reporting repository,” Dr. Guffey said. “The fact that we have a national reporting system, the full backing of the Anesthesia Quality Institute and all of that informatics capability allows us to take a best-in-class quality practice and make it a reality across the country.”

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