Issue |
J Extra Corpor Technol
Volume 42, Number 2, June 2010
|
|
---|---|---|
Page(s) | 158 - 162 | |
DOI | https://doi.org/10.1051/ject/201042158 | |
Published online | 15 June 2010 |
Technique Article
The Children’s Hospital Boston Non-Routine Event Reporting Program
Address correspondence to: Gregory S. Matte, BS, CCP, LP, Children’s Hospital Boston, 300 Longwood Avenue, FA-144, Boston, MA 02115. E-mail: Gregory.matte@cardio.chboston.org
Received:
16
November
2009
Accepted:
22
January
2010
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.
Key words: cardiopulmonary bypass / perfusion morbidity and mortality / prospective database / non-routine events
© 2010 AMSECT
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