13. the computerized anesthesia record: Quality assurance and medicolegal perspectives

Research output: Contribution to journalArticlepeer-review

Abstract

There is little doubt that large computer- generated anesthesia record databases provide excellent material for quality assurance purposes. It is unfortunate, however, that software for analysis of computerized anesthesia records is not yet well developed. Quality assurance reports of cardiac arrest over 17 years in a university hospital and clinical competency in a private practice setting have been reported (Acta Anaesthesiol Scand 1988; 32:653-64, QRBQual Rev Bull 1991; 17:182-93). The following is an example of a quality assurance study based on computer records (Anesth Analg 1995; 80:SCA87). Pulse oximeters have been reported to fail in 1.12-2.50% of cases using handwritten anesthesia records. Case files of 21,214 computerized anesthesia records from two hospitals and 1,119 handwritten records were reviewed. The mean pulse oximetry failure rate (> 10 min duration) in computerized anesthesia records was 8.20% compared with 2.0% in handwritten records. The most significant predictors of pulse oximetry failure were age (2-12yrs, >70yrs), ASA physical status 3,4, or 5, increasing duration of anesthesia, and type of surgery (e.g., orthopedic, vascular, and cardiac). Hypothermia, hypotension, and hypertension were also found to be associated with pulse oximetry failure. Thus, the objective nature of the computerized data collection provides both a realistic assessment of the limitations of the technology as well as a powerful research tool for assessing the causes of pulse oximetry failures. MedicolegalIssues: It is debatable whether computerized records are advantageous in malpractice claims. On the basis of several studies, advocates of computerized record keeping assert that manual records are neither accurate nor contemporaneous records of vital signs (J Surg Res 1977; 22:419-24). Cook, et. al. compared 46 handwritten and electromechanically generated blood pressure records and found substantial differences (Anesthesiology 1989; 71:385-90). The highest and lowest blood pressures that were recorded automatically exceeded the highest and lowest pressures found in corresponding handwritten records, respectively. More than one-third of records had at least three automatic blood pressure determinations with values substantially in excess of the most extreme values recorded by hand, and no handwritten record contained a diastolic pressure above 110 mmHg. They concluded that these discrepancies between handwritten and automatic records may arise because of automated readings unobserved by the anesthesiologist, faulty reconstruction of handwritten records from memory, and bias in favor of less controversial values. Other studies make similar points.(Acta Anaesthesiol Scand 1988; 32:653-64, J Clin Anesth 1992; 45:386-9). The purported medicolegal advantages of computerized record keeping may be summarized as follows: They provide an accurate time sequence of events, especially during critical incidents; The defense attorney will be able to assess the merits of a case; They will prove vigilance more often than negligence (Semin Anesth 1991; 10:41-7); and They are useful in refuting accusations of sloppiness and implied negligence. A recent article by Zeitlin of the ASA Committee on Professional Liability argued that automated records do not reduce anesthesia liability (ASA Newsletter 1995; 59 (6):21-23). These points may be summarized as follows: It is doubtful that computer records contain better information; The key to medicolegal defense is a thoughtful explanation of actions in the OR; The filtering and smoothing of extreme values is of data irrelevant to outcome and appropriate in an era of 'error-blame' mentality; Pulse oximetry and capnometry are applied universally because they are useful whereas computer records have never gained wide acceptance because they are not useful; and The Closed Claims Project data do not support the role of poor anesthesia records in unfavorable malpractice claims.

Original languageEnglish
Pages (from-to)202-203
Number of pages2
JournalInternational Journal of Clinical Monitoring and Computing
Volume13
Issue number3
StatePublished - 1996

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