Accuracy of text entries within a manually compiled anaesthetic record

Area of Science:

• Anesthesiology
• Medical Informatics
• Patient Safety

Background:

• Accurate documentation of perioperative events is essential for patient safety, clinical decision-making, and research.
• Manual anesthetic records are widely used but their accuracy has not been thoroughly evaluated.

Purpose of the Study:

• To assess the accuracy of text entries in manually compiled anesthetic records.
• To identify specific areas of inaccuracy and omission within these records.

Main Methods:

• A comparative analysis of anesthetic records from 197 procedures.
• An observer independently documented perioperative events to serve as a gold standard.
• Eighty-six distinct information items were analyzed for accuracy, omissions, and unwarranted entries.

Main Results:

• A mean omission rate of 35% and an incorrect entry rate of 3.4% were observed.
• Omissions were frequent for preoperative status, fluid management, tourniquet use, monitoring, local anesthesia, and intraoperative issues.
• Patient descriptions and intraoperative intravenous drug use were the most accurately recorded data points.

Conclusions:

• Significant deficiencies in anesthetic record accuracy exist, primarily due to omissions rather than incorrect entries.
• The findings suggest that record design and perceived value, not anesthetist defensiveness, contribute to inaccuracies.
• Improving the design and perceived utility of anesthetic records is vital to enhance data accuracy, patient safety, and medico-legal/epidemiological research.