Data recording of problems during anaesthesia: Presentation of a well-functioning and simple system

Background: As quality assurance, risk analysis and documentation become more important, rapid access to accurate information of departmental activity is needed. In this paper we describe a system for routine data recording of anaesthesia-related information, and we give examples of how this information can be used. Methods: For each anaesthesia procedure we record 20 variables in a database. The variables are related to the patient, the procedure, and the anaesthesia. Both the type and severity of intraoperative problems are recorded. All information is routinely written on the standard anaesthetic chart, and later entered into a database. All charts are quality checked before data entry. Results: With small modifications, we have used this system for 10 years, and it is well integrated as part of our departmental routine. From 1985 to 1995 we have recorded an increased incidence of 'minor' intraoperative problems, while the increase in 'severe' problems has been small. During the period 1993-95 the total problem incidence has been stable at around 14%. We have found the incidence of problems related to technical equipment to be 0.14%, and of 'minor' severity, and therefore equipment failure has not warranted extensive quality assurance efforts. We also investigated the impact of our routines for gastric emptying of non-fasting patients, and found an incidence of pulmonary aspiration of 0.03%. Our results made us conclude that our recommendations concerning anaesthetic technique and gastric emtying are safe. The system has proven to be simple enough to be practicable, and yet detailed enough to be informative for educational, quality assurance, research and administrative purposes. Conclusion: A simple database for information related to anaesthetic care and problems can be a useful tool for anaesthesiology departments. We have used the system for a variety of quality assurance efforts, for educational and administrative purposes and in research. To get reliable data it is important to keep the system simple, with the information recorded kept to a minimum. The software chosen must make it possible for people within the department to write and modify reports. A constant focus on data quality is important, and motivated nurses and doctors as well as leadership enthusiasm are necessary to make the system work properly. The atmosphere of problem recording should be one of 'openness and confidence', rather than 'inspection and control'. (C) Acta Anaesthesiologica Scandinavica 40 (1996)