Acute Anesthesia Charting Fidelity Quality Assessment Pilot Study

1. Primary Objective: Conduct a prospective, observational pilot study that assesses the frequency and severity of anesthesia charting fidelity weaknesses in three separate clinical environments (Cardiac surgical operating room, cardiac surgical intensive care unit, and electrophysiology laboratory) as assessed by a customized error scoring system that focuses on the magnitude of errors among multiple continuous, categorical and dichotomous variables. The errors are being assessed in order to identify the most common charting inaccuracies so that target areas appropriate for testing of improvement strategies may be isolated.

2. Cardiac surgical operating room: Any cardiac surgical procedure that involves the use of cardiopulmonary bypass and planned postoperative intensive care unit admission in an electronic supplemented anesthesia charting environment

3. Cardiac surgical intensive care unit: The cardiac surgical intensive care unit environment during the first 2-3 hours following procedures referenced in section I,A,1

4. Electrophysiology laboratory: select electrophysiology laboratory based procedures that employ a paper anesthesia chart

5. Secondary and Exploratory Objectives:

6. Identify environmental variables that contribute significantly to medical record errors.

7. Identify clinical role of individual responsible for charting

8. Investigate time of day/patterns that charting errors occur

9. Relationship of clinical acuity and event occurrences

10. Role of equipment malfunction and event frequency

11. Role of social distracters and event frequency

12. Role of monitor infidelity and event frequency

13. Role of delayed charting of event and frequency of errors

14. Identify/quantify the awareness of clinicians to their execution of medical record errors through use of simple, multiple choice 4 question survey that clinicians will be asked to fill out following a case study

15. Examine the relationship between the assessed environments and the frequency of medical charting errors

16. Identify the areas of anesthesia charting most in need of improvement in order to address designing ways to potentially improve these weaknesses.

Error scoring system:

1. The degree of charting fidelity error in this study will be converted via a classification system to make data analysis more efficient. All types of errors that involve continuous variables will be assessed with mean, median and standard deviation as well as range. Numerical data points related to time will be classified into four separate categories.