Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

Area of Science:

• Anesthesiology
• Patient Safety
• Quality Improvement

Background:

• The Veterans Health Administration (VHA) established a lessons learned process for anesthesia adverse events.
• This initiative aims to alert healthcare professionals to adverse event occurrences and prevention strategies.

Purpose of the Study:

• To detail a quality improvement project focused on anesthesia adverse events within the VHA.
• To assess the perceived impact and usefulness of the VHA's lessons learned process.

Main Methods:

• Root cause analyses of anesthesiology care adverse events are reported to the VHA National Center for Patient Safety.
• National Anesthesia Service experts and the National Center for Patient Safety collaborate to review events and develop lessons learned.
• A survey was distributed to anesthesiology chiefs in April 2018 to gauge the project's perceived usefulness and accessibility.

Main Results:

• The survey achieved a 69% response rate.
• 85% of respondents found the lessons learned valuable, and 90% shared them with staff.
• 75% reported a change in patient safety behavior, with 72% gaining new patient safety knowledge and 75% gaining knowledge on preventing adverse events.

Conclusions:

• The VHA's nationwide anesthesiology lessons learned project exemplifies a learning organization.
• Sharing lessons learned facilitates peer-to-peer learning and proactive error prevention.
• This process implements team and systems-based safeguards to mitigate harm from human error.