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ANESTHESIA INCIDENT REPORTING SYSTEM (AIRS)
REPORT EVENTS AT www.aqiairs.org
On October 1, 2011, the Anesthesia Quality Institute (AQI) activated the first nationwide system for collecting individual adverse events from anesthesia, pain management and perioperative care. We are calling it AIRS: the Anesthesia Incident Reporting System. AIRS is an online reporting tool easily accessed on the AQI website at http://www.aqiairs.org.
Critical incident reporting, based on either actual adverse events or “near misses” is a common concept in anesthesia department quality management (QM) at the local level. Most hospitals and most anesthesia departments mandate the reporting of critical or “sentinel” events, and most academic departments have regular “Morbidity and Mortality” conferences to discuss unusual cases. The AQI believes the time is ripe for a national system for reporting critical events in our specialty.
Who Can Report: Any anesthesia provider
What to Report: Any unintended event related to anesthesia or pain management with the significant potential for patient harm. Some examples are:
Unusual reaction to anesthetic medication
Unusual manifestation of patient disease/surgery
Challenging diagnostic situation
Novel or unexpected system failure
How to Report: Go to www.aqiairs.org and fill out the short form. AIRS contains special pages designed to report drug shortages, respiratory depression, and pediatric and obstetric cases.
All AIRS reports are made over a secure encrypted Internet connection and are maintained in strict confidence (and firewall isolation) on the AQI server. Reports can be made either anonymously (no record of sender) or confidentially (sender contact information retained). Confidential reporting allows the reporter to modify an initial report with follow-up information; it also allows AQI to contact the reporter to elucidate important or ambiguous details.
Legal protection is conferred by AQI’s standing as a Patient Safety Organization (PSO). Federal law protects any “patient safety work product” generated by an accredited PSO from legal discovery and in fact imposes strict guidelines on the way in which the PSO must preserve the confidentiality of its work. Per these regulations, the AQI may never reveal the identity of any patient, provider, facility or practice gathered through AIRS.
AIRS data is abstracted by a committee of physicians who help publish interesting cases which appear each month in the ASA Newsletter. The AIRS Committee will also periodically examine the entirety of AIRS for emerging trends in anesthesia patent safety.
Arnold Berry, MD - Emory University
Meir Chernofsky, MD - Uniformed Services University
Peter Fleischut, MD - New York-Presbyterian Hospital
David Gaba, MD — Stanford University
Patrick Guffey, MD — Children's Hospital Colorado & University of California San Francisco
David Martin, MD — Mayo Clinic Rochester
Patrick McCormick, MD — Mount Sinai New York
Alan Merry, MD — University of Auckland
Karen Nanji, MD - Massachusetts General Hospital
David Polaner, MD — University of Colorado Denver
Stephen Pratt, MD — Beth Israel Deaconess
David L. Robinowitz, MD - University of California San Francisco
Keith Ruskin, MD — Yale University
Marjorie Podraza Stiegler, MD - University of North Carolina, Chapel Hill
Avery Tung, MD — University of Chicago
Tetsu Uejima, MD - Ann and Robert H Lurie Children's Hospital of Chicago
Joyce Wahr, MD — University of Michigan
Richard Dutton, MD — Anesthesia Quality Institute
Full text article about AIRS in the October 2011 issue of the ASA Newsletter (PDF)
Slides on AIRS Event Reporting: Theory & Practice (PPT)
Richard P. Dutton, M.D., MBA, Executive Director of the Anesthesia Quality Institute (AQI) announces the organization's Anesthesia Incident Reporting System (AIRS). - PODCAST
Anesthesia Patient Safety Foundation (APSF) 2010 Medication Safety Conference Report (PDF)
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