title: Development, implementation and impact of simple patient safety interventions in a university teaching hospital.
abstract: OBJECTIVE
  To determine the incidence of anesthesia patient safety incidents at a university teaching hospital, develop interventions to address the most common incidents, and determine the effectiveness of these interventions.
  
  
  METHODS
  Pre-post intervention observational.
  
  
  METHODS
  Four thousand, one hundred forty dogs and cats anesthetized by the anesthesia service.
  
  
  METHODS
  The study was divided into two 11.5 month periods. During each period, incidents were logged (e.g. closed adjustable pressure limiting (APL) valve, esophageal intubation, and medication error). At the end of the first period, four countermeasures were incorporated into the service's protocols: 1) prior to any drug injection, the individual would read out aloud the drug name, patient name, and route of administration; 2) use of a uniquely colored occlusive wrap over arterial catheters; 3) a check box on the anesthesia record labeled "Technician Confirmed Intubation"; 4) a check box on the anesthesia record labeled "Technician Checked OR (operating room)". The number of patient safety incidents during period 1 and period 2 were compared using Fisher's Exact Test.
  
  
  RESULTS
  During Period 1, there were 74 incidents documented in 2028 patients (3.6%) including 25 medication errors, 20 closed APL valves, and 16 of esophageal intubation. During Period 2, there were 30 incidents documented in 2112 patients (1.4%) including 14 medication errors, 5 closed APL valves, and 4 of esophageal intubation. The proportion of events during Period 2 was significantly smaller than during Period 1 (p < 0.0001).
  
  
  CONCLUSIONS
  Implementation of four simple interventions was associated with a significant decrease in the number of incidents.
authors.affiliation: Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
authors.forename: Erik H
authors.initials: EH
authors.lastname: Hofmeister
authors.forename: Jane
authors.initials: J
authors.lastname: Quandt
authors.forename: Christina
authors.initials: C
authors.lastname: Braun
authors.forename: Molly
authors.initials: M
authors.lastname: Shepard
mesh_terms: D000768:Anesthesia, General / Q000009:adverse effects / Q000592:standards / Q000662:veterinary*; D000777:Anesthetics / Q000009:adverse effects / Q000494:pharmacology; D000818:Animals; D002415:Cats; D015331:Cohort Studies; D004285:Dogs; D006762:Hospitals, Animal / Q000592:standards*; D006785:Hospitals, University; D019300:Medical Errors / Q000517:prevention & control / Q000662:veterinary; D061214:Patient Safety; D011785:Quality Assurance, Health Care
chemical_list: D000777:Anesthetics
keywords: anesthesia; checklist; incident; risk