SURGERY OR ANESTHESIA

Transcription

1 Common Formats Aggregate Report Hospital SURGERY OR ANESTHESIA DEFINITION OF EVENT EVENTS INCLUSIONS Event type Incidents Harm No harm Can t tell about harm Near Miss SURGICAL EVENTS Surgical events that can only be incidents Surgical site infection Bleeding requiring return to the operating room Event with burn and/or operating room fire Burn Operating room fire Both Iatrogenic pneumothorax Unintended laceration or puncture Dehiscence; flap or wound failure or disruption; graft failure Unintended blockage, obstruction, or ligation Unplanned removal of organ Air embolus Other type of surgical event - incident Page 1 of 8

2 DEFINITION OF EVENT (continued) SURGICAL EVENTS Surgical events that can only be incidents (continued) Unintentionally retained object Type of object Sponge Needle Towel Whole instrument (e.g., clamp) Instrument fragment Other type of unintentionally retained object Object count Count performed Count correct (reconciled) Count incorrect (unreconciled) X-ray obtained X-ray not obtained Object radiopaque Object not radiopaque Can't tell about object Can't tell if x-ray obtained Count not performed Object not countable Object countable; count not done Can't tell whether count performed Page 2 of 8

3 DEFINITION OF EVENT (continued) SURGICAL EVENTS (continued) Surgical events that can be incidents or near misses Incorrect surgical or invasive procedure Incorrect patient Incidents Near misses Incorrect side Incidents Near misses Incorrect site Incidents Near misses Incorrect procedure Incidents Near misses Incorrect implant by mistake Incidents Near misses Incorrect implant because correct implant not available Incidents Near misses Other Incidents Near misses Other type of surgical event - near miss Page 3 of 8

4 DEFINITION OF EVENT (continued) ANESTHESIA EVENTS Anesthesia events Anesthesia adverse outcomes (incidents) Dental injury Ocular Injury Peripheral nerve injury Awareness (during anesthesia) Malignant hyperthermia Difficulty managing airway Difficulty during tracheal intubation Difficulty maintaining airway during procedure Esophageal intubation Re-intubation (following extubation) in operating or recovery room Other airway management problem Anesthesia process problems (incidents or near misses) Problem with anesthetic, medical gas, medication, or other substance Problem with anesthesia delivery device Other anesthesia events (processes or outcomes) (incidents or near misses) Page 4 of 8

5 DEFINITION OF EVENT (continued) MAJOR COMPLICATIONS Incidents that could be associated with either surgery or anesthesia Cardiac or circulatory event Central nervous system event Renal failure, impairment, or insufficiency Respiratory failure requiring unplanned respiratory support within 24 hours Type of respiratory support Prolonged ventilator support Re-institution of ventilator following discontinuation Other support Other type of major complication RISK ASSESSMENTS AND PREVENTIVE PATIENT S ASA PHYSICAL CLASSIFICATION Class Class Class Class Class ASA classification not documented Page 5 of 8

6 CIRCUMSTANCES OF EVENT DESCRIPTIVE INFORMATION Time of event discovery Before anesthesia started (or no anesthesia) After anesthesia started but before procedure started After procedure started but before procedure ended At closure, if a surgical operation After procedure ended but before patient left OR or procedure area During post-anesthesia care/recovery period After post-anesthesia recovery but before discharge After patient was discharged During anesthesia when no surgical operation or invasive procedure was performed Can t tell when event discovered Anesthesia or sedation Anesthesia or sedation used Type of anesthesia or sedation General anesthesia Regional anesthesia Local or topical anesthesia Sedation used alone Level of sedation Sedation used alone or with regional, local or topical anesthesia Deep Moderate Minimal Can t tell level of sedation Page 6 of 8

7 CIRCUMSTANCES OF EVENT (continued) DESCRIPTIVE INFORMATION Anesthesia or sedation (continued) Anesthesia or sedation used Person who administered anesthesia or sedation Anesthesiologist CRNA Supervised by anesthesiologist Not supervised by anesthesiologist Can t tell if supervised Other healthcare professional Can t tell who administered anesthesia or sedation Length of time from induction to end of general anesthesia Event with general anesthesia Less than 1 hour One or more hours, but less than 3 hours Three or more hours, but less than 5 hours Five hours or more Can t tell length of anesthesia No anesthesia or sedation used Can't tell about anesthesia or sedation Page 7 of 8

8 CIRCUMSTANCES OF EVENT (continued) DESCRIPTIVE INFORMATION (continued) Specialization of provider or team Anesthesiology Cardiology Colorectal surgery Dentistry, including oral surgery Dermatology Emergency medicine Family Medicine Gastroenterology General surgery Internal medicine Neurological surgery Obstetrics/Gynecology Ophthalmology Orthopedic surgery Otolaryngology Pediatrics Pediatric surgery Plastic surgery Podiatry Pulmonology Radiology, including vascular and interventional Thoracic surgery Urology Vascular surgery Other RISK FACTORS Emergency circumstances Procedure performed as an emergency Procedure not performed as an emergency Can t tell if emergency Page 8 of 8