Incidence and Classification of Nonroutine Events during Anesthesia Care

Abstract

Background A nonroutine event is any aspect of clinical care perceived by clinicians or trained observers as a deviation from optimal care based on the context of the clinical situation. The authors sought to delineate the incidence and nature of intraoperative nonroutine events during anesthesia care. Methods The authors prospectively collected audio, video, and relevant clinical information on 556 cases at three academic hospitals from 1998 to 2004. In addition to direct observation, anesthesia providers were surveyed for nonroutine event occurrence and details at the end of each study case. For the 511 cases with reviewable video, 400 cases had no reported nonroutine events and 111 cases had at least one nonroutine event reported. Each nonroutine event was analyzed by trained anesthesiologists. Rater reliability assessment, comparisons (nonroutine event vs. no event) of patient and case variables were performed. Results Of 511 cases, 111 (21.7%) contained 173 nonroutine events; 35.1% of event-containing cases had more than one nonroutine event. Of the 173 events, 69.4% were rated as having patient impact and 12.7% involved patient injury. Longer case duration (25th vs. 75th percentile; odds ratio, 1.83; 95% CI, 1.15 to 2.93; P = 0.032) and presence of a comorbid diagnosis (odds ratio, 2.14; 95% CI, 1.35 to 3.40; P = 0.001) were associated with nonroutine events. Common contributory factors were related to the patient (63.6% [110 of 173]) and anesthesia provider (59.0% [102 of 173]) categories. The most common patient impact events involved the cardiovascular system (37.4% [64 of 171]), airway (33.3% [57 of 171]), and human factors, drugs, or equipment (31.0% [53 of 171]). 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 Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Composition and Risk Assessment of Perioperative Patient Safety Incidents Reported by Anesthesiologists from 2009 to 2019, a single-center retrospective cohort study

“…Second, our study was a single-centre study, and the phenomenon of under-reporting was severe. What's more, nonroutine events without patient injury or even with mild patient physiologic disturbances might not be reported, although these events were also important for guiding organizational patient safety improvement interventions [24]. Consequently, the result might not re ect the whole picture.…”

Effect of implementing an anesthesia nurse checklist in a safety and teamwork climate: quasi-experimental study

“…To the domains "participation in the team" and "support for new ideas", the factors are composed of questions and statements presented on a Likert scale, with five answer alternatives: (5) strongly agree, (4) agree, (3) neither agree/neither disagree, (2) disagree and (1) strongly disagree. The domain "team goals" and "task orientation" have seven alternatives that indicate the agreement with the options described, measured respectively as (6-7) completely, (3-5) somewhat, or (1-2) no way, and (6-7) a lot, (3)(4)(5) to some extent or (1-2) a little (23) . Considering all domains, the score of the TCI scale varies from 38 to 226 points, whereby the higher the score, the better perception of teamwork climate.…”

“Nonroutine Events” as a Nonroutine Outcome for Perioperative Systems Research

“…Outcomes such as mortality in clinical and health services research are rare, limiting statistical power to show associations. In this issue of Anesthesiology, Liberman et al 1 present an alternative to rare outcome measures-one that they call "nonroutine events. "…”

“…In their research article, Liberman et al investigate nonroutine events by examining more than 500 anesthesia cases through collecting audiovisual recordings and provider surveys about the incidence of nonroutine events. 1 In their study, the authors define nonroutine events as "any aspect of clinical care perceived by clinicians or observers as a deviation from optimal care for that patient in that clinical situation" (emphasis in original); this definition was first proposed by Weinger et al in 2003. 3 The definition of nonroutine events purposefully includes subjective judgment to include many different types of events at the base of the accident pyramid that may lead to outright adverse events.…”

“…As demonstrated by Liberman et al, these events are quite common and are associated with more serious events that the authors call "patient impact events," which included difficulty with tracheal intubation, unstable hemodynamics, and equipment problems, among others. 1 It is plausible that a decrease in nonroutine events would translate into a decrease in patient impact events, which in turn would translate into a decrease in outcomes usually grouped into the category of morbidity and mortality. For small, single-center studies, it might be possible to select both a study design and sample size able to demonstrate a difference in nonroutine events, whereas larger, multicenter studies could more precisely describe the relationship between nonroutine events, patient impact events, morbidity, and mortality.…”