Common Formats Aggregate Report Hospital SURGERY OR ANESTHESIA DEFINITION OF EVENT EVENTS INCLUSIONS Event type Incidents 823 174 257 225 167 Harm 735 154 228 205 148 No harm 88 20 29 20 19 Can t tell about harm 0 0 0 0 0 Near Miss 167 42 52 40 33 SURGICAL EVENTS Surgical events that can only be incidents 417 99 125 105 88 Surgical site infection 162 41 57 34 30 Bleeding requiring return to the operating room 94 25 29 23 17 Event with burn and/or operating room fire 8 1 1 4 2 Burn 5 1 1 2 1 Operating room fire 1 0 0 1 0 Both 2 0 0 1 1 Iatrogenic pneumothorax 8 1 2 3 2 Unintended laceration or puncture 31 7 9 9 6 Dehiscence; flap or wound failure or disruption; graft 24 4 5 9 6 failure Unintended blockage, obstruction, or ligation 22 6 4 7 5 Unplanned removal of organ 5 1 1 2 1 Air embolus 2 1 0 0 1 Other type of surgical event - incident 10 1 3 4 2 Page 1 of 8
DEFINITION OF EVENT (continued) SURGICAL EVENTS Surgical events that can only be incidents (continued) 417 99 125 105 88 Unintentionally retained object 51 11 14 10 16 Type of object Sponge 36 8 10 7 11 Needle 11 2 3 3 3 Towel 1 1 0 0 0 Whole instrument (e.g., clamp) 0 0 0 0 0 Instrument fragment 1 0 0 0 1 Other type of unintentionally retained object 2 0 1 0 1 Object count Count performed 35 10 8 6 11 Count correct (reconciled) 23 7 5 4 7 Count incorrect (unreconciled) 12 3 3 2 4 X-ray obtained 4 2 1 1 0 X-ray not obtained 6 1 2 1 2 Object radiopaque 3 1 1 0 1 Object not radiopaque 2 0 1 1 0 Can't tell about object 1 0 0 0 1 Can't tell if x-ray obtained 2 0 0 0 2 Count not performed 12 1 4 3 4 Object not countable 8 0 3 2 3 Object countable; count not done 4 1 1 1 1 Can't tell whether count performed 4 0 2 1 1 Page 2 of 8
DEFINITION OF EVENT (continued) SURGICAL EVENTS (continued) Surgical events that can be incidents or near misses 182 45 64 40 33 Incorrect surgical or invasive procedure 182 45 64 40 33 Incorrect patient 15 4 5 3 3 Incidents 6 2 2 1 1 Near misses 9 2 3 2 2 Incorrect side 122 30 41 29 22 Incidents 49 11 17 12 9 Near misses 73 19 24 17 13 Incorrect site 25 7 9 5 4 Incidents 14 4 5 3 2 Near misses 11 3 4 2 2 Incorrect procedure 17 4 6 3 4 Incidents 7 2 2 1 2 Near misses 10 2 4 2 2 Incorrect implant by mistake 3 0 3 0 0 Incidents 2 0 2 0 0 Near misses 1 0 1 0 0 Incorrect implant because correct implant not available 0 0 0 0 0 Incidents 0 0 0 0 0 Near misses 0 0 0 0 0 Other 0 0 0 0 0 Incidents 0 0 0 0 0 Near misses 0 0 0 0 0 Other type of surgical event - near miss 0 0 0 0 0 Page 3 of 8
DEFINITION OF EVENT (continued) ANESTHESIA EVENTS Anesthesia events 290 47 87 95 61 Anesthesia adverse outcomes (incidents) 167 30 50 52 35 Dental injury 10 3 1 4 2 Ocular Injury 1 0 0 1 0 Peripheral nerve injury 13 4 5 1 3 Awareness (during anesthesia) 5 2 2 0 1 Malignant hyperthermia 1 1 0 0 0 Difficulty managing airway 137 20 42 46 29 Difficulty during tracheal intubation 66 11 21 22 12 Difficulty maintaining airway during procedure 24 2 6 10 6 Esophageal intubation 32 5 9 10 8 Re-intubation (following extubation) in operating or 10 1 5 2 2 recovery room Other airway management problem 5 1 1 2 1 Anesthesia process problems (incidents or near 120 16 37 42 25 misses) Problem with anesthetic, medical gas, medication, or 62 10 22 20 10 other substance Problem with anesthesia delivery device 58 6 15 22 15 Other anesthesia events (processes or outcomes) (incidents or near misses) 3 1 0 1 1 Page 4 of 8
DEFINITION OF EVENT (continued) MAJOR COMPLICATIONS Incidents that could be associated with either surgery or 101 25 33 25 18 anesthesia Cardiac or circulatory event 52 15 18 11 8 Central nervous system event 12 3 3 2 4 Renal failure, impairment, or insufficiency 11 2 3 4 2 Respiratory failure requiring unplanned respiratory 24 5 9 7 3 support within 24 hours Type of respiratory support Prolonged ventilator support 17 5 6 4 2 Re-institution of ventilator following discontinuation 3 0 1 1 1 Other support 4 0 2 2 0 Other type of major complication 2 0 0 1 1 RISK ASSESSMENTS AND PREVENTIVE PATIENT S ASA PHYSICAL CLASSIFICATION Class 1 587 128 204 152 103 Class 2 314 64 79 98 73 Class 3 34 8 9 6 11 Class 4 35 11 10 5 9 Class 5 9 4 4 0 1 ASA classification not documented 11 1 3 4 3 Page 5 of 8
CIRCUMSTANCES OF EVENT DESCRIPTIVE INFORMATION Time of event discovery Before anesthesia started (or no anesthesia) 43 11 15 9 8 After anesthesia started but before procedure started 127 26 45 32 24 After procedure started but before procedure ended 161 35 47 47 32 At closure, if a surgical operation 89 17 41 19 12 After procedure ended but before patient left OR or 85 21 25 22 17 procedure area During post-anesthesia care/recovery period 102 21 30 31 20 After post-anesthesia recovery but before discharge 322 78 86 85 73 After patient was discharged 45 5 16 15 9 During anesthesia when no surgical operation or invasive 5 1 1 1 2 procedure was performed Can t tell when event discovered 11 1 3 4 3 Anesthesia or sedation Anesthesia or sedation used 939 197 294 255 193 Type of anesthesia or sedation General anesthesia 623 141 187 161 134 Regional anesthesia 117 23 41 32 21 Local or topical anesthesia 73 11 28 20 14 Sedation used alone 126 22 38 42 24 Level of sedation Sedation used alone or with regional, local or topical 262 37 92 83 50 anesthesia Deep 23 4 6 8 5 Moderate 207 29 77 63 38 Minimal 27 3 7 10 7 Can t tell level of sedation 5 1 2 2 0 Page 6 of 8
CIRCUMSTANCES OF EVENT (continued) DESCRIPTIVE INFORMATION Anesthesia or sedation (continued) Anesthesia or sedation used 939 197 294 255 193 Person who administered anesthesia or sedation Anesthesiologist 514 103 172 142 97 CRNA 338 82 93 86 77 Supervised by anesthesiologist 235 58 67 58 52 Not supervised by anesthesiologist 116 24 25 26 24 Can t tell if supervised 4 0 1 2 1 Other healthcare professional 76 11 26 23 16 Can t tell who administered anesthesia or sedation 11 1 3 4 3 Length of time from induction to end of general anesthesia Event with general anesthesia 623 141 187 161 134 Less than 1 hour 190 52 61 46 31 One or more hours, but less than 3 hours 288 59 86 71 72 Three or more hours, but less than 5 hours 105 21 29 33 22 Five hours or more 30 7 8 9 6 Can t tell length of anesthesia 10 2 3 2 3 No anesthesia or sedation used 50 5 21 14 10 Can't tell about anesthesia or sedation 1 0 0 1 0 Page 7 of 8
CIRCUMSTANCES OF EVENT (continued) DESCRIPTIVE INFORMATION (continued) Specialization of provider or team Anesthesiology 8 1 2 3 2 Cardiology 12 5 2 2 3 Colorectal surgery 44 8 11 14 11 Dentistry, including oral surgery 7 3 4 0 0 Dermatology 4 0 1 2 1 Emergency medicine 8 3 3 2 0 Family Medicine 8 3 0 1 4 Gastroenterology 24 2 6 10 6 General surgery 184 58 63 34 29 Internal medicine 7 0 3 2 2 Neurological surgery 84 18 25 24 17 Obstetrics/Gynecology 85 9 23 32 21 Ophthalmology 15 2 3 3 7 Orthopedic surgery 110 49 27 11 23 Otolaryngology 14 3 2 5 4 Pediatrics 4 0 1 2 1 Pediatric surgery 36 8 9 10 9 Plastic surgery 8 1 2 3 2 Podiatry 5 1 1 2 1 Pulmonology 4 0 1 2 1 Radiology, including vascular and interventional 11 4 2 1 4 Thoracic surgery 104 17 52 19 16 Urology 105 11 41 42 11 Vascular surgery 99 10 25 39 25 Other 0 0 0 0 0 RISK FACTORS Emergency circumstances Procedure performed as an emergency 106 23 33 28 22 Procedure not performed as an emergency 860 191 270 227 172 Can t tell if emergency 24 2 6 10 6 Page 8 of 8