Beyond adverse events in anesthesiology: 'unanticipated events' and strategies for improved reporting.

PURPOSE OF REVIEW

Patient safety in anesthesiology has advanced significantly over the past several decades. The current process of improving care is often based on studying adverse events (AEs) and near misses. However, there is a wealth of information not captured by focusing solely on these events, potentially resulting in missed opportunities for care improvements.

RECENT FINDINGS

We review terms such as AEs and nonroutine events (NREs), and introduce the concept of unanticipated events (UEs), defined as events that deviate from intended care that may/may not have been caused by error, may/may not be preventable, and may/may not have caused injury to a patient. UEs incorporate AEs in addition to many other anesthetic events not routinely tracked, allowing for trend analysis over time and the identification of additional opportunities for quality improvement. We review both automated and self-reporting tools that currently exist to capture this often-neglected wealth of data. Finally, we discuss the responsibility of quality/safety leaders for data monitoring.

SUMMARY

Consistent reporting and monitoring for trends related to UEs could allow departments to identify risks and mitigate harm before it occurs. We review various proposed methods to expand data collection, and recommend anesthesia practices pursue UE tracking through department-specific reporting interfaces.