Anesthesia-Specific Software Module for Voluntary Adverse Event Reporting

Hospital staff are expected to report adverse events to safety leaders and risk managers. At our institution, staff report adverse events via an incident reporting software system, known as "RL." These "RL reports" are kept separate from patient medical records. Within the Anesthesiology Department, we noted low numbers of RL reports relative to known adverse events. Anesthesiology-related events were scattered within the RL software and therefore difficult to find. We hypothesized that compiling these events in one location would increase reporting rates and allow for deeper analysis of filed adverse events.

We created an Anesthesia-specific RL software module, which included all anesthesia-related adverse events in one location. Additionally, we tracked the impact on RL reporting of two other quality improvement initiatives, including an intradepartmental quality assurance form, implemented during the study period.

The Anesthesia RL software module led to a 3.2-fold increase (P < 0.001) in the monthly average of filed RL reports. The increase was even greater (11.1-fold, P < 0.001) when excluding the most prevalent category of RL reports (Controlled Substance Discrepancies). The intradepartmental quality assurance form had minimal impact on filed RL reports. "Controlled Substance Discrepancies," "Other," and "Equipment issue" were the most common event types. Most events were classified as constituting no harm to the patient.

Creating a specialty-specific RL software module led to increased RL reports, even when accounting for other implemented quality improvement initiatives, and allowed for deeper analysis of the filed reports. Our findings may be replicated for other specialties.