The reliability of manual reporting of clinical events in an anesthesia information management system (AIMS)

• DOI: 10.1007/s10877-012-9371-z
• Publication Date: 2012-05-21T14:46:32Z
• Authors: Allan F. Simpao; Eric Y. Pruitt; Scott D. Cook-Sather; Harshad G. Gurnaney; Mohamed A. Rehman
• Keywords: 0209 industrial biotechnology; Medical Records Systems, Computerized; Predictive Value of Tests; Vomiting; Child, Preschool; Humans; Anesthesia; Documentation; 02 engineering and technology; Child; Sensitivity and Specificity

Manual incident reports significantly under-report adverse clinical events when compared with automated recordings of intraoperative data. Our goal was to determine the reliability of AIMS and CQI reports of adverse clinical events that had been witnessed and recorded by research assistants. The AIMS and CQI records of 995 patients aged 2-12 years were analyzed to determine if anesthesia providers had properly documented the emesis events that were observed and recorded by research assistants who were present in the operating room at the time of induction. Research assistants recorded eight cases of emesis during induction that were confirmed with the attending anesthesiologist at the time of induction. AIMS yielded a sensitivity of 38 % (95 % confidence interval [CI] 8.5-75.5 %), while the sensitivity of CQI reporting was 13 % (95 % CI 0.3-52.7 %). The low sensitivities of the AIMS and CQI reports suggest that user-reported AIMS and CQI data do not reliably include significant clinical events.