An Analysis of Quality Assurance Events in Nonoperating Room Anesthetizing Locations: A Qualitative Retrospective Cohort Study.

Abstract

Nonoperating room anesthesia (NORA) poses unique challenges to the anesthesia clinician, yet existing evidence on patient safety in NORA is limited. The aim of this study was to characterize NORA quality assurance (QA) events at a large academic health system based on a validated qualitative framework to provide insights and suggest potential safety interventions. This two-center qualitative retrospective cohort study included all adult NORA cases performed between August 1, 2018, and December 31, 2022. QA event reporting was mandatory for every anesthetic during the study. The analyzed dataset included anesthesia clinician QA event reports associated with an optional free response comment, and each comment was coded using both deductive and inductive approaches in parallel. Each QA event was categorized in an inductive fashion, and the System Engineering Initiative for Patient Safety (SEIPS) framework was used to categorize event descriptions deductively. Emerging categories and representative scenarios were summarized. A total of 497,175 cases were performed during the study period, of which 106,476 (21.4%) were performed in NORA locations. After applying exclusion criteria, 984 QA report free-response comments were analyzed. Diverse subcategories emerged among the QA event categories (eg, employee safety concerns, patient positioning issues, unclear protocols). Some of the commonly identified SEIPS categories were "Organization" and "Tools and technology." From deductive and inductive analyses, challenges with teamwork, communication, care processes, variability in access to equipment, and equipment malfunctions were identified in the NORA setting. In addition to patient outcomes, negative organizational and employee outcomes were described on account of NORA-specific complexities. This large qualitative study characterized NORA QA events across multiple dimensions. Our findings highlight that QA events in NORA are complex and often due to a combination of factors, underscoring both clinical and systems-level vulnerabilities. These findings may provide a framework for targeted quality improvement interventions.