Accuracy of Vasopressor Documentation in Anesthesia Records

Area of Science:

• Anesthesiology
• Pharmacology
• Medical Informatics

Background:

• Accurate documentation of vasoactive medication administration is crucial for patient safety and research.
• Anesthetic records are primary sources for clinical data analysis.

Purpose of the Study:

• To evaluate the accuracy of documenting vasoactive medication administration in anesthetic records.
• To identify the extent of documentation omissions for vasopressors.

Main Methods:

• A cross-sectional observational study was conducted at a single academic center.
• An auditor inspected anesthesia workstations and reviewed anesthesia records for vasopressor administration.
• The study focused on cases involving phenylephrine and/or ephedrine boluses.

Main Results:

• Full documentation of vasopressor boluses was found in only 26% of cases.
• No documentation was recorded in 36% of cases.
• Partial documentation occurred in 38% of cases, with a median of 50% of the total dose documented.

Conclusions:

• Complete or partial omission of vasopressor documentation is common in anesthesia records.
• Inaccurate documentation can compromise the integrity of clinical data registries and retrospective studies.
• Improved documentation practices are necessary to ensure data reliability.