SA members have expressed interest in the graphical displays relating to anesthesia-related sentinel events on the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) Web site.

Specifically, some have wondered whether the apparent increase in the number of anesthesia-related sentinel events in 2004 was related to increased reporting of unanticipated intraoperative awareness under general anesthesia. ASA requested details behind the data, and JCAHO responded as follows.

The questions pertain to data charts showing the numbers of anesthesia-related sentinel events that have been reviewed by the Joint Commission under its Sentinel Event Policy and the patterns of root causes identified for these events.

The chart of anesthesia-related sentinel events reviewed by year shows an apparent increase in 2004 as compared to previous years.* These data should be interpreted with caution due to the very low level of reporting of these events. We estimate that, overall, less than 1 percent of all sentinel events are brought to the attention of the Joint Commission. The “increased number” of reported anesthesia-related events was 15 for the entire year, nationally. Given the very low level of reporting for this and other types of sentinel events, it is not surprising that there is considerable variation from year to year, especially for those less frequently reported types of events. We do not interpret this as showing a trend.

The 49 anesthesia-related sentinel events all resulted in death or major permanent loss of function. That is, they meet the first element of the Joint Commission’s definition of a reviewable sentinel event: “The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition.”

Of the 49 anesthesia-related events, 35 involved general anesthesia, two spinal, eight epidural and four sedation.

Of the 49 events, two occurred pre-induction, 15 during induction/intubation, 23 during anesthesia, three during emergence and six in the postanesthesia care unit.

Regarding the chart showing categories of root causes for anesthesia-related events, the percentages indicate the frequency with which a particular category of root cause was identified in the 49 root-cause analyses for this type of event. Typically there are multiple root causes identified for each event, so it is expected that the percentages will total more than 100 percent. On average, across all types of events, there are slightly more than three root causes identified per event.