Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia

Area of Science:

• Pediatric Anesthesiology
• Patient Safety
• Quality Improvement

Background:

• The Society for Pediatric Anesthesia established Wake Up Safe (WUS) in 2006.
• WUS is a patient safety organization collecting de-identified data on serious adverse events in pediatric anesthesiology.
• Its goal is to enhance the quality and safety of anesthetic care for children across the nation.

Purpose of the Study:

• To review the development and background of the Wake Up Safe patient safety initiative.
• To describe the standardized root cause analysis (RCA) method employed by WUS members.
• To demonstrate the application of the RCA method using a reported serious adverse event.

Main Methods:

• Member institutions submit data on anesthetics performed and serious adverse events.
• A standardized root cause analysis (RCA) is performed by uninvolved anesthesiologists for each reported event.
• WUS provides education on RCA methods to standardize analysis across member institutions.

Main Results:

• The WUS registry collects data on serious adverse events in pediatric anesthetics.
• A standardized RCA method is utilized to identify causal factors in adverse events.
• The initiative aims to use collected data to drive improvements in pediatric anesthetic care.

Conclusions:

• Wake Up Safe is a key initiative for improving pediatric patient safety in anesthesiology.
• Standardized root cause analysis is crucial for evaluating and learning from adverse events.
• Data from WUS will be instrumental in promoting safer anesthetic practices for children.