Development, implementation and impact of simple patient safety interventions in a university teaching hospital

Vet Anaesth Analg. 2014 May;41(3):243-8. doi: 10.1111/vaa.12124. Epub 2014 Feb 27.


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.

Study design: Pre-post intervention observational.

Animals: 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 and clinical relevance: Implementation of four simple interventions was associated with a significant decrease in the number of incidents.

Keywords: anesthesia; checklist; incident; risk.

MeSH terms

  • Anesthesia, General / adverse effects
  • Anesthesia, General / standards
  • Anesthesia, General / veterinary*
  • Anesthetics / adverse effects
  • Anesthetics / pharmacology
  • Animals
  • Cats*
  • Cohort Studies
  • Dogs*
  • Hospitals, Animal / standards*
  • Hospitals, University
  • Medical Errors / prevention & control
  • Medical Errors / veterinary
  • Patient Safety*
  • Quality Assurance, Health Care


  • Anesthetics