Interventions increase reporting of adverse events by pediatric anesthesiologists

Editor's Note

Electronic mandatory incident reporting system data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in adverse event reporting by pediatric anesthesiologists, in this study.

Of 72,384 pediatric anesthetics analyzed, there were 2,689 adverse events. A subgroup of 54,469 cases had 529 serious adverse events in 440 anesthetics. Cardiac, respiratory, and airway events predominated.

After implementing mandatory incident reporting data entry and a quality improvement initiative that involved interviewing pediatric anesthesiologists about incident reporting barriers and motivators, the rate of incident reporting per 10,000 anesthetics increased from 149 to 387.

Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value.

The barriers were addressed by incident reporting education, cultivating a culture of safety that encouraged reporting, reporter feedback, and more inclusion of anesthesiologists in patient safety work.

pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member.

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