Composition and risk assessment of perioperative patient safety incidents reported by anesthesiologists from 2009 to 2019: a single\u2010center retrospective cohort study

Xue Zhang,Hui Pan,Xueqin Sun,Weiyun Chen,Yuguang Huang,Xiuhua Zhang,Qing Chang,Shuang Ma,Yuelun Zhang,Le Shen

doi:10.1186/s12871-020-01226-0

Abstract

BackgroundPatient safety incident (PSI) reporting has been an important means of improving patient safety and enhancing organizational quality control. Reports of anesthesia-related incidents are of great value for analysis to improve perioperative patient safety. However, the utilization of incident data is far from sufficient, especially in developing countries such as China.MethodsAll PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and August 2019 were collected from the incident reporting system. We reviewed the freeform text reports, supplemented with information from the patient medical record system. Composition analysis and risk assessment were performed.ResultsIn total, 847 PSIs were voluntarily reported by anesthesiologists during the study period among 452,974 anesthetic procedures, with a reported incidence of 0.17%. Patients with a worse ASA physical status were more likely to be involved in a PSI. The most common type of incident was related to the airway (N = 208, 27%), followed by the heart, brain and vascular system (N = 99, 13%) and pharmacological incidents (N = 79, 10%). Those preventable incidents with extreme or high risk were identified through risk assessment to serve as a reference for the implementation of more standard operating procedures by the department.ConclusionsThis study describes the characteristics of 847 PSIs voluntarily reported by anesthesiologists within eleven years in a Chinese academic hospital. Airway incidents constitute the majority of incidents reported by anesthesiologists. Underreporting is common in China, and the importance of summarizing and utilizing anesthesia incident data should be scrutinized.

Highlights

Patient safety incident (PSI) reporting has been an important means of improving patient safety and enhancing organizational quality control
Of the 847 PSIs voluntarily reported by anesthesiologists from September 2009 to August 2019, 74 cases were excluded because they had already been reported or were not related to anesthesia
We analyzed 847 PSIs voluntarily reported by anesthesiologists within eleven years in a Chinese teaching hospital

Summary

Introduction

Patient safety incident (PSI) reporting has been an important means of improving patient safety and enhancing organizational quality control. PSI reporting has been an important means of improving patient safety and enhancing organizational quality control Many developed countries, such as the United States of America, Australia, the United Kingdom and Germany, have had national PSI reporting systems for prospective collection of PSI data since 1993 [2,3,4,5,6]. Hospitals in England and Wales are obligated to report PSIs to the UK National Reporting and Learning Service (NRLS), and data are periodically analyzed at the national level These systems encourage the blame-free submission of incident reports, with the aim of identifying such defects before causing harm [3]. Few studies have characterized incidents from anesthesia practice, and none of these have been from developing countries

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