Newly Published
Editorial  |   May 2020
“Nonroutine Events” as a Nonroutine Outcome for Perioperative Systems Research
Author Notes
  • From the Department of Anesthesiology and Critical Care, Perelman School of Medicine, Center for Perioperative Outcomes Research and Transformation, and Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, Pennsylvania (M.B.L.-F.); Department of Health Systems and Sciences Research, College of Nursing and Health Professions, and Department of Information Science, College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania (E.J.B.).
  • This editorial accompanies the article on p. XXX.
    This editorial accompanies the article on p. XXX.×
  • Accepted for publication November 4, 2019.
    Accepted for publication November 4, 2019.×
  • Correspondence: Address correspondence to Dr. Lane-Fall:
Article Information
Editorial   |   May 2020
“Nonroutine Events” as a Nonroutine Outcome for Perioperative Systems Research
Anesthesiology Newly Published on May 8, 2020. doi:
Anesthesiology Newly Published on May 8, 2020. doi:
Perioperative safety and systems research has long been stymied by the weak, inconsistent relationship between healthcare interventions and classic outcomes of interest such as mortality. As members of the anesthesia care team, we know intuitively that our individual and collective behaviors influence patient outcomes. Why, then, is it so difficult to empirically demonstrate such a relationship in 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 creating and evaluating systems meant to reduce harm, industrial engineers consider a principle represented using the “accident triangle” (fig. 1) that relates frequent, low-importance events to infrequent, high-importance events such as mortality.2  Quality and safety professionals in health care have largely adopted this principle, creating robust systems to capture near misses and deviations from care processes. Taking cues from aerospace, aviation, manufacturing, and nuclear power, healthcare safety systems such as critical incident reporting systems examine threats both prospectively and retrospectively and strongly emphasize voluntary reporting of events and near-events by on the ground staff. Such voluntary reporting systems are valuable because they enable the identification of events with the potential to lead to harm and, across reports, enable the characterization of patterns that might signal a systemic problem. Unfortunately, even with mechanisms to protect reporters from retaliation or even self-incrimination, reporting systems only capture what people choose to report. For this reason, there is no information about base rates, which limits the ability of these systems to shed light on safety trends over time.