Newly Published
Perioperative Medicine  |   May 2020
Incidence and Classification of Nonroutine Events during Anesthesia Care
Author Notes
  • From the Geriatric Research Education and Clinical Center, Tennessee Valley Veterans Affairs Healthcare System, Nashville (J.S.L., J.M.S., M.B.W.); the Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center (J.S.L., J.M.S., G.W., M.S.S., E.P., M.B.W.); and the Departments of Anesthesiology (all authors); Biomedical Informatics (M.B.W.), and Biostatistics (M.S.S.), Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, Tennessee.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Early incomplete aspects of this work were presented at the 2002 meeting of the Association of University Anesthetists on April 12, 2002 in Nashville, Tennessee and the 2004 International Anesthesia Research Society annual meeting on March 27, 2004 in Tampa, Florida.
    Early incomplete aspects of this work were presented at the 2002 meeting of the Association of University Anesthetists on April 12, 2002 in Nashville, Tennessee and the 2004 International Anesthesia Research Society annual meeting on March 27, 2004 in Tampa, Florida.×
  • Submitted for publication December 27, 2018. Accepted for publication March 31, 2020.
    Submitted for publication December 27, 2018. Accepted for publication March 31, 2020.×
  • Correspondence: Address correspondence to Dr. Liberman: Center for Research and Innovation in Systems Safety, 1211 21st Avenue South, Medical Arts Building, Suite 732, Nashville, Tennessee 37212. justin.s.liberman@vumc.org. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine
Perioperative Medicine   |   May 2020
Incidence and Classification of Nonroutine Events during Anesthesia Care
Anesthesiology Newly Published on May 8, 2020. doi:https://doi.org/10.1097/ALN.0000000000003336
Anesthesiology Newly Published on May 8, 2020. doi:https://doi.org/10.1097/ALN.0000000000003336
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:

  • A nonroutine event is defined as any aspect of clinical care perceived by clinicians or observers as a deviation from optimal care for a patient in a clinical situation

  • Nonroutine events are frequent and associated with increased clinician workload and patient physiologic disturbances

What This Article Tells Us That Is New:

  • Video recordings of 511 cases from 1998 to 2004 were viewed to identify nonroutine events, which occurred in 22% of cases, and some cases had multiple events

  • One in fifteen patients had events associated with some degree of patient injury

  • The most common contributory factors were related to provider, patient, or teaching/supervision