National pediatric anesthesia safety quality improvement program in the United States

Anesthesia and Analgesia

Volumn 119, Issue 1, 2014, Pages 112-121

  Kurth, C Dean ^a   Tyler, Don ^b   Heitmiller, Eugenie ^c   Tosone, Steven R ^d   Martin, Lynn ^e   Deshpande, Jayant K ^f  

^a UNIVERSITY OF CINCINNATI COLLEGE OF MEDICINE   (United States)

^b UNIVERSITY OF PENNSYLVANIA   (United States)

^c JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^d EMORY UNIVERSITY SCHOOL OF MEDICINE   (United States)

^e UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE   (United States)

^f UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHETIC AGENT;

ANESTHESIST; ANESTHETIC EQUIPMENT; ARTICLE; CARDIOVASCULAR DISEASE; DRUG QUALITY; DRUG SAFETY; HEALTH PROGRAM; HEART ARREST; HUMAN; INCIDENCE; INFORMATION SYSTEM; LEADERSHIP; MEDICAL DEVICE COMPLICATION; MEDICAL EDUCATION; MEDICATION ERROR; ORGANIZATIONAL STRUCTURE; PEDIATRIC ANESTHESIA; PRIORITY JOURNAL; RESPIRATORY TRACT DISEASE; TOTAL QUALITY MANAGEMENT; UNITED STATES;

ANESTHESIA; CHILD; HUMANS; PATIENT SAFETY; PEDIATRICS; QUALITY IMPROVEMENT; UNITED STATES;

EID: 84903267034     PISSN: 00032999     EISSN: 15267598     Source Type: Journal    
DOI: 10.1213/ANE.0000000000000040     Document Type: Article

References (27)

1. Cooper, Jeffrey B.; Newbower, Ronald S.; Long, Charlene D.; McPeek, Bucknam: Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399-406
2. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984;60:34-42 (Pubitemid 14178927)
3. Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11 (Pubitemid 18059810)
4. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 1990;72:828-33 (Pubitemid 20149216)
5. Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse anesthetic outcomes arising from gas delivery equipment: a closed claims analysis. Anesthesiology 1997;87:741-8 (Pubitemid 27456225)
6. Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW. Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology 1989;71:541-6 (Pubitemid 19241489)
7. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg 2007;105:344-50 (Pubitemid 47196409)
8. Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: a closed claims analysis. Anesthesiology 1999;91:1703-11
9. Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, Domino KB, Posner K, Cheney FW. Anesthesia-related cardiac arrest in children: initial fndings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology 2000;93:6-14 (Pubitemid 30436671)
10. Ramamoorthy C, Haberkern CM, Bhananker SM, Domino KB, Posner KL, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesth Analg 2010;110:1376-82
11. Murat I, Constant I, Maud'huy H. Perioperative anaesthetic morbidity in children: a database of 24, 165 anaesthetics over a 30-month period. Paediatr Anaesth 2004;14:158-66 (Pubitemid 38297225)
12. Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourc'h G. Complications related to anaesthesia in infants and children. A prospective survey of 40240 anaesthetics. Br J Anaesth 1988;61:263-9
13. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009;108:795-804
14. Tay CL, Tan GM, Ng SB. Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore. Paediatr Anaesth 2001;11:711-8 (Pubitemid 33033480)
15. Bennett D, Marcus R, Stokes M. Incidents and complications during pediatric cardiac catheterization. Paediatr Anaesth 2005;15:1083-8 (Pubitemid 43965386)
16. Flick R P, Sprung J, Harrison TE, Gleich SJ, Schroeder DR, Hanson AC, Buenvenida SL, Warner DO. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92, 881 patients. Anesthesiology 2007;106: 226-37 (Pubitemid 46185166)
17. van der Griend BF, Lister NA, McKenzie IM, Martin N, Ragg PG, Sheppard SJ, Davidson AJ. Postoperative mortality in children after 101, 885 anesthetics at a tertiary pediatric hospital. Anesth Analg 2011;112:1440-7
18. Couloures KG, Beach M, Cravero JP, Monroe KK, Hertzog JH. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics 2011;127:e1154-60
19. Luria JW, Muething SE, Schoettker PJ, Kotagal UR. Reliability science and patient safety. Pediatr Clin North Am 2006;53:1121-33 (Pubitemid 44779683)
20. Nolan T, Resar R, Haraden C. Improving the Reliability of Health Care. Cambridge, MA: Institute for Healthcare Improvement, 2004
21. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Effectiveness. San Francisco, CA: Jossey-Bass, 2009. P 13-216, 433-440, 456-464
22. Kurth CD. Introducing quality improvement. Paediatr Anaesth 2013;23:569-70
23. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S; SQUIRE Development Group. Publication guidelines for quality improvement in health care: evolution of the SQUIRE project. Qual Saf Health Care 2008;17 Suppl 1:i3-9
24. Standards for Quality Improvement Reporting Excellence. http://squire-statement.org/guidelines/. Accessed December 6, 2013
25. Marcus R. Human factors in pediatric anesthesia incidents. Paediatr Anaesth 2006;16:242-50
26. MacLennan AI, Smith AF. An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006-2008. Paediatr Anaesth 2011;21:841-7
27. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 1990;70:160-7 (Pubitemid 20045079)