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Type: Journal article
Title: Adverse physiological events under anaesthesia and sedation: a pilot audit of electronic patient records
Author: Grant, C.
Ludbrook, G.
Hampson, E.
Semenov, R.
Willis, R.
Citation: Anaesthesia and Intensive Care, 2008; 36(2):222-229
Publisher: Australian Soc Anaesthetists
Issue Date: 2008
ISSN: 0310-057X
Statement of
C. Grant, G. Ludbrook, E. A. Hampson, R. Semenov and R. Willis
Abstract: Review of perioperative activity, including adverse events, throughput and compliance with 'best practice, can theoretically be used to optimise healthcare delivery. Computer-based analysis of electronic patient records could provide a practical means to manage quality improvement. This pilot study examined the effectiveness of such a system in practice. All intraoperative patient notes and physiological data were collected over 17 months in a rural hospital using data from an electronic record-keeping system. Algorithms were developed to automatically identify potential adverse events based on physiological measures. Each computer-identified event was reviewed by a panel of three anaesthetists and assessed for validity, severity and probable cause. Two areas were identified to pilot quality improvement activities-sedation for colonoscopies and inhalational anaesthesia with desflurane. Specific 'in-house' guidelines were created for these procedures and feedback on the patterns of adverse events were provided to anaesthetic staff. A total of 138 separate adverse events were identified for all operative cases over 17 months, with an overall adverse event incidence of 3.3%. The adverse event incidence during colonoscopy and laryngospasm/hypoxia during desflurane anaesthesia was 6.3% and 1.3% respectively. This decreased to 2.8% (P <0.005) and 0.13% (P <0.0001) respectively for the nine months following feedback and the introduction of guidelines. Anaesthesia information systems can be an effective quality improvement tool and may enhance existing tools such as incident reporting systems.
Keywords: adverse events; anaesthesia; sedation; anaesthesia information systems; quality improvement
Rights: COPYRIGHT © 2008 Australian Society of Anaesthetists
RMID: 0020080575
DOI: 10.1177/0310057x0803600213
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Appears in Collections:Medicine publications

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