title: The Children's Hospital Boston non-routine event reporting program.
abstract: Several authors have described methods to track perfusion and cardiac surgical morbidity and mortality as well as perfusion accidents. There is currently not a standard definition of a perfusion accident nor is there a standard reporting threshold for events which do not directly cause known morbidity. We propose the term non-routine events (NREs) instead of accidents, and provide a working definition and reporting threshold for such. This paper describes the program which we developed to track perfusion NREs within the Cardiovascular Program at Children's Hospital, Boston. NREs are categorized by type (technique, equipment, or patient-related) and bypass period (pre-cardiopulmonary bypass, bypass, or post-cardiopulmonary). NRE outcomes are also classified by the level of discussion or change in perfusion practice after multidisciplinary review. We have documented during a 44 month interval that 42% (29/69) of reported NREs occur during the bypass period and are equipment related and thus, efforts to improve practice should focus there. We have also seen a generally decreasing incidence of NREs requiring either a change in perfusion practice or a new protocol during this time period. We believe that our regular multidisciplinary meetings to discuss NREs have increased awareness among the entire team about potential problems in the program and that intuitively, it has improved patient safety.
authors.affiliation: Children's Hospital Boston, Department of Cardiovascular Surgery, 300 Longwood Avenue, FA-144, Boston, MA 02115, USA. Gregory.matte@cardio.chboston.org
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Matte
authors.forename: Daniel
authors.initials: D
authors.lastname: Riley
authors.forename: Robert
authors.initials: R
authors.lastname: LaPierre
authors.forename: Robert
authors.initials: R
authors.lastname: Howe
authors.forename: Mark
authors.initials: M
authors.lastname: Anderson
authors.forename: Sharon
authors.initials: S
authors.lastname: Boyle
authors.forename: Linda
authors.initials: L
authors.lastname: Durham
authors.forename: William
authors.initials: W
authors.lastname: Regan
authors.forename: Frank
authors.initials: F
authors.lastname: Pigula
mesh_terms: D001900:Boston; D005112:Extracorporeal Circulation / Q000592:standards*; D019221:Mandatory Reporting; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000458:organization & administration*; D012308:Risk Management / Q000379:methods* / Q000458:organization & administration*