Veterinary Anaesthesia and Analgesia, 2016, 43, 128135
12309
RESEARCH PAPER
Adverse event surveillance in small animal anaesthesia: an
intervention-based, voluntary reporting audit
Matthew McMillan & Hannah Darcy
Department of Veterinary Medicine, Queens Veterinary School Hospital, University of Cambridge, Cambridge, UK
Correspondence: Matthew McMillan, Queens Veterinary School Hospital, Department of Veterinary Medicine, University of Cambridge,
Madingley Road, Cambridge CB3 0ES, UK. E-mail: mwm32@cam.ac.uk
Present address: Hannah Darcy, Chaseview Veterinary Clinic, Ross-on-Wye, UK
Abstract
Objective To develop, test and refine an interven-
tion-based system for the surveillance of adverse
events (AEs) during small animal anaesthesia.
Studydesign Prospective, voluntary reporting audit.
Animals A total of 1386 consecutive small animal
anaesthetics (including 972 dogs and 387 cats).
Methods Adverse events were defined as undesir-
able perianaesthetic events requiring remedial inter-
vention to prevent or limit patient morbidity. Using
previous reports, 11 common AEs were selected and
intervention-based definitions were devised. A vol-
untary reporting audit was performed over 1 year at
a university teaching hospital. Data on AEs were
collected via paper checkbox forms completed after
each anaesthetic and were assimilated using an
electronic database. Interventions were performed
entirely at the discretion of the attending anaes-
thetist. Comparisons between dogs and cats were
made using Fishers exact tests.
Results Forms were completed for 1114 anaesthet-
ics (a compliance of 80.4%), with 1001 AEs reported
in 572 patients. The relative frequency of AEs
reported were as follows: arousal or breakthrough
pain (14.9%), hypoventilation (13.5%), hypotension
(10.3%), arrhythmias (5.8%), hyperthermia/hy-
pothermia (5.0%), airway complications (4.8%),
recovery excitation (4.6%), aspiration risk (4.5%),
desaturation (2.8%), hypertension (1.7%) and
other (3.7%). Canine anaesthetics (57.3%) were
more likely to involve AEs than were feline anaes-
thetics (35.5%, p < 0.01). Escalation in postanaes-
128
doi:10.1111/vaa.
thetic care was required in 20% of cases where an
AE was reported (8% of anaesthetics overall). In 6%
of cases (2% overall), this involved management in
an intensive care unit. There were six intra-anaes-
thetic fatalities (0.43%) during this period. The tool
was widely accepted, being considered quick and
easy to complete, but several semantic, logistical and
personnel factors were encountered.
Conclusions and clinical relevance Simple inter-
vention-based surveillance tools can be easily inte-
grated into small animal anaesthetic practice,
providing a valuable evidence base for anaesthetists.
A number of considerations must be addressed to
ensure compliance and the quality of data collected.
Keywords adverse events, anaesthesia, audit, inter-
vention, safety.
Introduction
The accurate reporting of adverse events (AEs) is
regarded as a fundamental cornerstone of patient
safety culture and the development of evidence-based
practice (Cooper et al. 1978; Department of Health
2000; Kohn et al. 2000; Mellin-Olsen et al. 2010;
Bell 2011; Gisvold & Fasting 2011). Despite this,
large-scale studies investigating AEs in small animal
anaesthesia are performed infrequently (Clarke & Hall
1990; Dyson et al. 1998; Gaynor et al. 1999;
Redondo et al. 2007) with recent audits concentrat-
ing predominantly on reporting perianaesthetic fatal-
ities (Brodbelt et al. 2008; Bille et al. 2012, 2014; Gil
& Redondo 2013). This focus on fatality, although
clearly important and relevant, inevitably slows the
rate at which safety improvements can be made
(Boelle et al. 2000; Gisvold & Fasting 2011).

One major obstacle to large-scale audit is the lack
of consensus over what to report and also how
events should be defined and classified. This incon-
sistency means that data collected from individual
studies are difficult to aggregate and compare,
limiting efforts to produce evidence-based recom-
mendations (Green & Yealy 2009). As a conse-
quence, the development of uniform definitions and
reporting templates has been recommended in
human medicine (Cummins et al. 1991; Bhatt et al.
2009; Mason et al. 2012). Key examples of such
templates are seen in the fields of cardiopulmonary
resuscitation (the Utstein style) and sedation [the
Quebec guidelines and the World Society of Intra-
venous Anaesthesias International Sedation Task
Force (ISTF) AE reporting tool] (Cummins et al.
1991; Bhatt et al. 2009; Mason & Green 2012).
Both the Quebec guidelines and the ISTF suggest
moving away from a traditional event and thresh-
old approach to an intervention-based system of
AE definition and reporting. Event and threshold
definitions are based on a parameter reaching a
specified critical threshold (e.g. mean blood pressure
dropping below 60 mmHg could define hypoten-
sion). In contrast, the basis of intervention-based
definitions of AEs is whether or not remedial actions
are made in response to a particular event with the
aim of halting escalation and limiting consequences
(e.g. an intervention such as a crystalloid or colloid
bolus made in response to a drop in blood pressure
could define hypotension). Despite appearing less
intuitive and more subjective, reported benefits of
this approach include providing a better reflection of
the clinical relevance of AEs and more objective,
unambiguous and reproducible data that can be
more readily aggregated and compared (Bhatt et al.
2009; Green & Yealy 2009; Mason & Green 2012).
Our initial objectives were threefold: first, to develop
and implement an intervention-based, AE surveil-
lance tool in a university teaching hospital; secondly,
to report its findings over a year-long pilot period; and,
finally, to describe its evolution over the first year of
reporting. The overall aim of the project was to
suggest a potential template for a surveillance tool for
veterinary anaesthesia by which readily comparable
AE data could be captured in a wide-scale fashion.
Materials and methods
The study was designed as a prospective, voluntary
reporting audit of small animal anaesthetic AEs
using a purpose-built, intervention-based AE surveil-
2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135
Adverse event surveillance M McMillan and H Darcy
lance tool. The study was approved by the local
ethics and welfare committee as part of a larger
study proposal (reference QVSH/CR41).
Development of the surveillance tool
Applying the principles set out in Bhatt et al. (2009)
and Mason & Green (2012), AEs were defined as
undesirable perianaesthetic events that required
remedial intervention in an attempt to prevent or
limit patient morbidity, mortality, distress or dis-
comfort.
Using previous reports in the literature regarding
AEs and complications in both human and veteri-
nary anaesthesia, a reference list of AEs and inter-
ventions was drawn up (Cooper et al. 1987; Clarke
& Hall 1990; Dyson et al. 1998; Gaynor et al. 1999;
Callum et al. 2000; Redondo et al. 2007). This
initial list was abbreviated by amalgamating indi-
vidual AEs into broader categories (e.g. apnoea,
respiratory arrest, hypoventilation and abnormal
respiratory patterns into a single ventilation cate-
gory). AEs were selected based on their reported
frequency of occurrence (Clarke & Hall 1990;
Gaynor et al. 1999) and on their general signifi-
cance in terms of patient morbidity and mortality (as
judged by the authors). Generic intervention-based
definitions were developed for each of these AE
categories using the definitions outlined by Bhatt
et al. (2009) as a basic framework. Remedial
actions, treatments, procedures or an escalation in
the level of care were all considered as interventions.
Some of the more serious events (such as hypox-
aemia) also had a secondary component to their
descriptors to assist in their assessment.
A total of 11 AEs were included in the predom-
inantly checkbox-based surveillance tool, which was
circulated on a single page of A4 paper on the
reverse side of the anaesthetic pricing sheet used to
bill for anaesthesia services. AE definitions, further
descriptors and interventions associated with them
are shown in Fig. 1. In addition, a number of free
text areas and a section for AEs that did not fall into
the main categories were provided. Finally, an
outcomes section which included death, euthanasia
and various potential escalations in the level of care
that could be prescribed as a direct consequence of
the AE(s) (above and beyond standard postanaes-
thetic care for that type of procedure), was included.
Testing of the surveillance tool
A prospective, voluntary reporting audit of AEs
encountered during small animal anaesthetics was
129
Adverse event surveillance M McMillan and H Darcy

Please complete for all patients: WERE THERE ONE OR MORE ADVERSE EVENTS (AEs) DURING THIS ANAESTHESIA?
NO (this form is now complete) YES (please fill out the remainder of the form)
Outcomes as direct consequences of the AE(s): *Which severity statement best fits the AE(s) encountered?
*Cancelled or shortened procedure MINOR Presented little threat of permanent harm to the patient
*Additional treatments MODERATE Threatened significant harm but was managed well
Additional monitoring, observations *or diagnostics
MAJOR Caused morbidity but outcome attenuated by
*Additional hospitalisation intervention
Escalation of patient care requiring <24 h (additional) ICU care
CATASTROPHIC Caused mortality or significant morbidity
Escalation of patient care requiring >24 h (additional) ICU care
Patient euthanased Further details:
Patient died

*CARDIOPULMONARY ARREST: Any event requiring cardiopulmonary resuscitation

HYPOPERFUSION/HYPOTENSION: Intervention made due to concerns over hypotension or poor perfusion
Description: Intervention:
Was hypotension secondary to blood loss? YES Significant decrease in *Significant change in planned
NO anaesthetic depth anaesthetic
*If yes, please estimate blood loss: ______ % or Crystalloid bolus(es) Pharmacological support
______ mL kg1 *Approx total vol:.........mL kg1 What?......................................
*Lowest SAP ____mmHg or MAP ____mmHg observed Colloid bolus(es) Other
1
*Approx duration of hypotension ____minutes *Approx total vol:.........mL kg What?......................................
ARRHYTHMIA: Any abnormal cardiac rhythm that required intervention
Description: Intervention:
Bradyarrhythmia Rate: ____ bpm & Rhythm ______________ Anticholinergic Other
Tachyarrhythmia Rate: ____ bpm & Rhythm ______________ Lidocaine What?......................................
Other arrhythmia Rate: ____ bpm & Rhythm ______________ Atipamezole .................................................
VENTILATION: Unplanned intervention made due to concerns over hypoventilation, apnoea, or abnormal respiratory pattern
Description: Intervention:
Hypoventilation that required intervention Short term IPPV Significantly decrease in
Respiratory arrest or apnoea Prolonged IPPV anaesthetic depth
Undesirable respiratory pattern that required intervention Antagonism of drugs Other
Other (please describe.......................................................................) What?...................................... What?......................................
HYPOXAEMIA: Intervention made due to concerns over oxygenation
Description: Intervention:
Any event of SpO2 <80% Increase FIO2 Recruitment manoeuvre
Any event of SpO2 80-93% with duration >60s IPPV PEEP
Any event of SpO2 80-93% with duration <60s Pharmacological intervention Other
Other (please describe.......................................................................) What?...................................... What?......................................
AIRWAY COMPLICATIONS: Intervention taken due to airway compromise
Description:
Difficult intubation Significant accidental disconnection Other
Failure of airway device (e.g. cuff deflated) Blockage of ET tube What?..........................................................
POTENTIAL ASPIRATION: Fluid identified in the oro-naso-pharyngeal-laryngeal region
Description: Intervention:
Reflux/regurgitation Other Suctioned Other
Haemorrhage What?...................................... Flushed What?......................................
Aspiration: Confirmed Probable Unlikely Omeprazole .................................................
AROUSAL/BREAKTHROUGH PAIN: Any event that required an unplanned bolus of induction agent or analgesic
RECOVERY AGITATION/EMERGENCE DYSPHORIA: Any event that required intervention due to the quality of recovery
TEMPERATURE REGULATION: Body temperature alteration that required additional (beyond standard) re-warming or patient cooling
Description: Intervention:
Hypothermia <36C (please specify lowest temperature ___C) Heat pad *Body cavity lavage
Hyperthermia >39C (please specify highest temperature ___C) Hot air blanket Other
Fluid warmer What?......................................
*EQUIPMENT OR MEDICATION ISSUES:
APL valve left closed IV access failure Other
O2 empty Wrong drug administered? What?..........................................................
Anaesthetic machine not fully prepared Wrong dose administered? .....................................................................
Other equipment not fully prepared Drug administered via wrong route? .....................................................................
DRUG REACTION: ANY OTHER EVENTS: *FURTHER REPORTING
Description & Intervention: Description & Intervention: FOR SIGNIFICANT EVENTS OR WHERE ERROR,
ACCIDENT OR MISJUDGEMENT WERE
INVOLVED IN THE AE(s) PLEASE ALSO
COMPLETE THE PATIENT SAFETY INCIDENT
REPORTING TOOL

Figure 1 The final revised adverse event surveillance tool. An asterisk (*) indicates that the following description, intervention
or section (including all subsequent descriptions and interventions associated with it) was not present on the original tool. In
addition, the order of interventions and the position of the ongoing intervention section, which was formerly at the bottom of
the tool, have been altered from the original. All other areas (including definitions) are consistent with the original.

performed in a multidisciplinary, university teaching case load, respectively). All small animal anaesthet-
hospital. The hospital admits both referral and first ics, with the exclusion of anaesthesia for radiother-
opinion patients (approximately 75% and 25% of apy, were eligible. Anaesthetists were asked to fill in

130 2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135

the AE surveillance tool immediately after every
eligible anaesthetic, but, although it was strongly
encouraged, completion was not made compulsory.
No guidance as to how it should be completed was
given.
Data were collected from all AE reports submitted
between June 2012 and June 2013. During the pilot
period, anaesthetic AEs were reportable up until the
point at which the patient was transferred to the
recovery room and no attempt was made to gather
follow-up data. AEs were investigated in isolation,
i.e. variables such as patient signalment, health
status, anaesthetic technique and surgical procedure
were not collected. No effort was made to gather
information from anaesthetics with missing AE
reports. Each paper report was uploaded manually
by a single investigator onto a purpose-built elec-
tronic database (Microsoft Access, Microsoft, WA,
USA) for analysis. An accurate total for the number
of anaesthetics performed during the period was
determined from hospital records.
Clinical monitoring (consisting of assessment of
pulse rate and quality, mucous membrane colour
and capillary refill time, respiration and depth of
anaesthesia), capnography and pulse oximetry
were utilized in all anaesthetized patients. Nonin-
vasive blood pressure monitoring (either Doppler
flowmetry or oscillometry) was used in all but the
shortest anaesthetics. Beyond this, the manage-
ment of patients, including selection of drugs,
additional monitoring devices and AE interven-
tions, was left entirely to the discretion of the
attending anaesthetist. Electronic monitoring was
performed using monitors of various makes and
models.
Prior to commencing the pilot audit, all staff
involved with the provision of anaesthesia (three
specialist veterinary anaesthetists, two anaesthesia
residents and one anaesthesia nurse) were made
aware that, although the reports would not be
anonymous, the data collected were for quality
improvement and research purposes only and that
it was not intended as an audit of their individual
performance.
Refinement of the surveillance tool
Informal interviews with members of the anaesthe-
sia team and final-year undergraduate students
exposed to the surveillance tool were used to reveal
limitations and weaknesses with the tool. Open case
discussion permitted subjective comparison of the
2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135
Adverse event surveillance M McMillan and H Darcy
AE report with the retrospective global assessment of
the anaesthetist.
At the end of the pilot period, each individual item
in the tool was analysed for reporting trends and
patterns. AE descriptor and intervention sections
(including free text sections) were assessed in terms
of their frequency of reporting/use, structure and
format and their importance to the audit. Based on
these findings and a final consultation with members
of the anaesthesia team, a revised version of the
surveillance tool was developed. Amendments con-
sidered included addition of questions, expanding or
removing descriptors and options, rewording of
questions, increasing the emphasis on particular
questions by altering their position on the form or
even complete removal of the question from the
form.
Statistical analysis
Data were analysed using mainly descriptive statis-
tics. Compliance was calculated as the percentage of
forms completed as compared with the total number
of anaesthetics performed during the same time
period. Overall and monthly compliance rates were
calculated. Where forms were absent it was assumed
that no significant AEs had occurred. Fishers exact
tests were used to assess the difference in frequency
of overall and individual AEs between cats and dogs.
All calculations were performed using a standard
spreadsheet program (Microsoft Excel 2007) or a
standard statistical software package (Graphpad
Prism; Graphpad Software Inc, CA, USA).
Results
Quantitative results
A total of 1386 anaesthetics were logged on the
hospitals electronic patient record system during
the pilot period. In all, 972 dogs, 387 cats, 18 rabbits
and nine other animals from various species (in-
cluding guinea pigs, ferrets and rats) were anaes-
thetized, and 1114 AE reports were submitted.
Overall compliance was 80.4% with monthly com-
pliance rates varying from 70% to 100%. Peaks of
poor compliance were observed during periods when
the lead investigator was not on clinical duty or
where there were staff shortages or locum anaes-
thetists working in the clinic.
A total of 1001 AEs were reported in 572 patients,
with 258 patients having more than one AE reported
131
Adverse event surveillance M McMillan and H Darcy
during the course of their anaesthetic, details of
which are reported in Table 1. Dogs were more likely
to develop AEs (454 of 793, 57.3%) than cats (106 of
299, 35.5%) (p < 0.01). The frequency of each AE,
both in total and broken down into dogs and cats, is
reported in Table 2. The management of hypotension
displayed the greatest variation in intervention and is
reported in Table 3. Intra-anaesthetic deaths and
predicted outcomes (in terms of escalation in the level
of care prescribed) were recorded in 353 (61.7%) of
the anaesthetics with AEs and these are reported in
Table 4. The intra-anaesthetic fatality rate of 0.43%
was confirmed to be accurate by checking hospital
records (no deaths went unreported).
Qualitative assessment
The consensus opinion was that the tool was flexible,
quick and simple to use and that, by and large, the
reports generated mirrored the clinical impression of
the anaesthetist at the time of the anaesthetic. The
main reasons given for not completing forms were
forgetfulness and time constraints. There was con-
cern that in some circumstances the report still failed
to highlight important events from lesser events. A
number of additional secondary descriptors were
suggested to help further classify various AEs. It also
became apparent that, although it was considered
useful, the importance of the outcomes section had
been under-emphasized. It was suggested that this
section be expanded to include outcomes such as
additional treatments, diagnostics and shortened or
cancelled procedures. An overall global severity scale
in terms of the impact of the AEs on the patient was
also recommended. Alterations made to the tool in
response to these concerns are marked in Fig. 1.
Table 1 The number of adverse events (AEs) reported per
anaesthetic in a voluntary reporting audit of 1386 small
animal anaesthetics in a university teaching hospital.
Where no report was filled in it was assumed no adverse
event had occurred
Number of AEs per case Frequency (relative frequency)
0 814 (58.7%)
1 314 (22.7%)
2 143 (10.3%)
3 70 (5.1%)
4 34 (2.5%)
5 10 (0.7%)
6 1 (0.1%)
132 2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135
Discussion
This study reports on the development, pilot and
evolution of an intervention-based AE surveillance
tool in a small animal university teaching hospital.
The results of the pilot are encouraging, as the
reports generated, by and large, appeared propor-
tional to the concerns of the anaesthetist expressed
during informal case reviews.
There are a number of limitations and sources of
bias associated with intervention-based reporting
systems that warrant discussion. To start with,
individual anaesthetists clinical judgement and
thresholds for intervening in particular circum-
stances may differ, introducing an element of sub-
jectivity with regard to when an AE report is
triggered (Green & Yealy 2009). However, in terms
of data gain and loss, this subjectivity is likely to
involve minor events only, as it can be assumed that
the more severe and important events will elicit an
intervention from any competent anaesthetist once
they are identified (Green & Yealy 2009).
Another limitation is that self-limiting events are
ignored using this system so there is the real
potential for AEs to be missed (Bhatt et al. 2009).
However, this bias is counteracted by the reporting
of potentially much more significant events, those
that are rectified by acting on impending problems in
advance of measured parameters deteriorating to a
reporting threshold (Bhatt et al. 2009). Overall the
effect on reporting is likely to be positive in terms of
clinically significant AEs.
There is also concern over whether interventions
alone can properly describe an AE. This can be
problematic with any reporting method, as it is
inevitable that during an AE the anaesthetist will be
preoccupied with trying to counter the AE rather
than classifying it in terms of precise measurement
(Bhatt et al. 2009). However, when retrospectively
reporting an AE, it is perhaps more likely that the
type and degree of intervention will be accurately
recalled and recorded. Clearly not all interventions
can be weighted equally; however, the type, number
and magnitude of interventions can be considered as
surrogate markers of the severity of events (Mason &
Green 2012).
There are also a number of limitations regarding
voluntary reporting systems, most notably a typi-
cally low reporting rate (Garrouste-Orgeas et al.
2012). Reasons cited for under-reporting include
time constraints; lack of an appropriate reporting
tool; fear of repercussions; concerns over case man-
 Adverse event surveillance M McMillan and H Darcy

Table 2 Absolute and relative frequencies of anaesthetic cases with individual adverse events (AEs) from a voluntary
reporting audit of 1114 small animal anesthesia cases in a university teaching hospital

Absolute Relative Absolute Relative Absolute Relative

frequency frequency frequency frequency frequency frequency
AE overall (n) overall (%) in dogs (n) in dogs (%) in cats (n) in cats (%)

Arousal and breakthrough pain* 206 14.9 174 21.9 32 10.7

Hypoventilation* 187 13.5 158 19.9 29 9.7
Hypotension* 143 10.3 134 16.9 9 3.0
Arrhythmia* 80 5.8 66 8.3 14 4.7
Bradycardia 47 3.4 42 5.3 5 1.7
Tachycardia 19 1.4 16 2.0 3 1.0
Other arrhythmia 22 1.6 16 2.0 6 2.0
Temperature regulation 69 5.0 46 5.8 23 7.7
Hypothermia 50 3.6 29 3.7 21 7.0
Hyperthermia 19 1.4 17 2.1 2 0.7
Airway complications* 67 4.8 39 4.9 28 9.4
Recovery excitation or 64 4.6 55 6.9 9 3.0
emergence dysphoria*
Potential aspiration* 63 4.5 56 7.1 7 2.3
Desaturation 39 2.8 30 3.8 9 3.0
Hypertension (not pain-related)* 23 1.7 22 2.8 1 0.3
Other 51 3.7 39 4.9 12 4.0
Equipment failure or malfunction 11 0.8 10 1.3 1 0.3
Failure of intravenous or 6 0.4 6 0.8 0 NA
intra-arterial cannula
Seizures or convulsions 5 0.4 2 0.3 3 1.0
(at induction or recovery)
Drug reactions 9 0.6 9 1.1 0 NA
Total AEs 1001 828 173

NA, not applicable. *Denotes statistically significant difference (p < 0.05) between cats and dogs.

Table 3 Absolute and relative frequencies of interventions 80.4%, which is comparable to similar voluntary
performed in the 143 anaesthetics during which hypoten-
self-reporting systems in human anaesthesia (Haller
sion was reported. Significant intraoperative haemorrhage
et al. 2011). This would appear to be a positive
was thought to be the cause of hypotension in only 12.6%
(n = 18) of cases
finding, but it is likely that sustaining this level would
require considerable and continued effort.
Finally, although the form itself could be com-
Absolute Relative
pleted rapidly, additional time was required to enter
Intervention performed frequency (n) frequency (%)
this data into the electronic database. In a university
Significant decrease in 127 88.8
hospital setting, this posed only a minor problem but
vaporizer setting it may make the surveillance tool difficult to intro-
Crystalloid bolus 59 41.3
duce into an environment where there are greater
Colloid bolus 47 32.9
Direct pharmacological 42 29.4 time constraints.
intervention with Despite these limitations, we believe this study
vasopressors,
inotropes or chronotropes
demonstrates that a simple reporting tool using an
Blood transfusion 5 3.5 intervention-based approach to defining AEs can be
Total 280
successfully integrated into small animal anaes-
thetic practice. Such tools could be used to gener-
ate useful data with minimal effort. The generic
agement, judgement and clinical decision-making descriptors and checkbox design of the tool
being scrutinized; a reluctance in clinicians to report appeared to be intuitive to use and the data were
their own errors and misjudgements; uncertainty of easy to gather, code and analyse. The location of the
the clinical importance of events; and the lack of form on the reverse of a universal piece of patient
change following reporting (Garrouste-Orgeas et al. record-keeping helped to remind staff to report after
2012). During the pilot period, the compliance was each case.

2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135 133
Adverse event surveillance M McMillan and H Darcy

Table 4 Intra-anaesthetic deaths, euthanasia and out- to individual cases requiring further in-depth review;
comes in terms of various potential escalations in the level and to study the impact of changes in clinical practice
of care (above and beyond standard postanaesthetic care on improving patient safety.
for that type of procedure) in the 353 cases where they As well as giving the opportunity to develop the
were predicted
surveillance tool, the pilot audit yielded some inter-
esting results with regard to AE incidence. Although
Relative our novel methodology makes direct comparison
Absolute frequency in with previous studies difficult, it is interesting to note
frequency cases where
that we observed similar incidences of some AEs
(number of outcome
Outcome cases) predicted (%) (such as hypotension) but not others (such as
hypoventilation and arrhythmia) (Gaynor et al.
No further action required 228 64.6 1999). The significance of this is uncertain and it
Increased level of 114 32.3 may be linked different tolerances to hypercapnia
monitoring/observations
Unintended period of 36 10.2 between the two hospitals and the fact that many
intensive care <24 hours arrhythmias that occur under anaesthesia require
Unintended period of 10 2.8
intensive care >24 hours
no intervention.
Did not recover from 11 0.8 The incidences of two AE categories, arousal or
anaesthesia
breakthrough pain and recovery excitation or
Intra-anaesthetic deaths 6 [2] 0.4 [0.1]
[of which were primarily (of all cases) emergence dysphoria, have not been reported
a result of anaesthesia] previously, which suggests that they are under-
Euthanased 5 0.4 (of all cases)
recognized problems in veterinary anaesthesia. The
increased incidence of AEs in dogs as compared with
cats is also an interesting finding. The reason for this
Not all components of the tool were fully success- is unclear, although it is possible that improved
ful and a number of amendments had to be made, functioning of electronic monitoring equipment in
but it should be noted that the intervention-based larger patients enables more marginal alterations in
definitions were consistent between the pilot and the physiological status to be recognized, thus triggering
final revision (apart from the addition of sections for an increased intervention rate.
reporting cardiopulmonary arrest and equipment We believe this method of gathering AE data is
and medication issues). One concern was that some more applicable to a wider range of circumstances
more clinically significant AEs were not distinguish- than other systems. Intervention-based systems do
able from lesser AEs. Expansion of the secondary AE not require specific data or precise measurements,
descriptors as a failsafe, a technique advocated by but rather rely on the interpretation of events by the
the ISTF, should attenuate this issue and enable the anaesthetist in light of the clinical situation. For
tool to consistently identify AEs of greater severity example, although clearly electronic devices such as
(Mason & Green 2012). On reflection, the least blood pressure monitors will facilitate decision-
successful section was the one investigating ongoing making, there is no absolute requirement for such
interventions. However, although redesign and re- equipment to trigger reporting of an event. Inter-
emphasis of this section were necessary, the princi- vention-based definitions allow the anaesthetist the
ple of reporting outcomes in terms of escalation of flexibility to consider interventions based on other
care was considered useful. clinical variables, such as pulse quality, to trigger a
Admittedly, the tools reports are not detailed report. This makes this method more applicable to
enough to give a full depiction of the anaesthetic and general practice and field settings.
any problems encountered during it. For example, Further adaptation and refinement are necessary
with the exception of hypotension caused by haem- for this tool to be useful on a wider scale. Developing it
orrhage, no attempt was made to separate the in an electronic format will enable easier, more rapid
aetiology of AEs. However, it is important to recognize data entry and allow integration into a practices
that this is not the objective of AE surveillance, which electronic patient record system (Haller et al. 2007).
is to give a global view of frequency and severity of Creation of smartphone or tablet computer applica-
AEs occurring during anaesthesia. This global view tions would open up further avenues for data
can be used to highlight areas warranting further collection in all environments where anaesthesia is
investigation, analysis and action; to draw attention performed, enabling rapid and large-scale data

134 2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia, 43, 128135

collection. Such methods have the potential to
facilitate clinical auditing and large-scale AE data-
bases.
In conclusion, the intervention-based AE surveil-
lance tool appeared to be a versatile, effective and
efficient method with which to generate useful AE
data. As with all methods of surveillance there are
some limitations to its use, but these limitations are
balanced by the simplicity and applicability of the
method.
Acknowledgements
The authors would like to acknowledge the signif-
icant contribution of Alex Chebroux in developing
the surveillance tool and electronic databasing
system used for this study.
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