An Exploration of “Near-Miss” Events in Non-Operating Room Anesthesia Locations

BACKGROUND: The Non-Operating Room Anesthesia (NORA) Safety Project is an exploratory prospective cohort study examining the incidence of near-miss events in NORA settings. While adverse events are typically well captured because of quality improvement programs that exist in most major health settings, near-miss events are often not documented, and safety standards are not well established. We present the results of a dedicated forum for near-miss reporting, including the incidence and type of near-miss events, as a first step toward understanding NORA near misses. By providing granular data from a highly engaged audience, we aimed to highlight evidence-backed opportunities for improving safety culture in the procedural landscape. METHODS: We surveyed all in-hospital NORA cases excluding pediatrics, those performed in the intensive care unit, or the peri-partum areas. The day of data collection was rotated weekly. Providers surveyed included anesthesiologists, nurse anesthetists, and anesthesiology residents. REDCap survey was sent via secure e-mail. If a near-miss event occurred, respondents were asked to classify their events in the following categories: patient, provider, and/or environment. RESULTS: Over a 42-week period, 1383 completed surveys were received in which 90 near-miss events were reported. Filtering for near misses reported on study data collection days and removing voluntary near misses from our total survey responses, our incidence rate was 3. 22% (43/1336). The top near-miss locations were the magnetic resonance imaging suite (21/90 23. 3%) and both neuro and body interventional radiology suites (15/90 16. 7% and 11/90 12. 2%, respectively). The top near-miss category was environmental concerns (75/90 83. 3%), and top subcategory was poor group dynamics (31/90 34. 4%). Significant characteristics in the near-miss patients included older age (mean ±standard deviation SD 60. 8 ±16. 9 vs 56. 8 ±17. 3 years P =. 03), male (52/90, 57. 8% vs 586/1293, 45. 3% P =. 03), higher American Society of Anesthesiologists (ASA) physical status (III and IV 65/90, 72. 2% P <. 001), longer procedure (119. 8 ± 108. 9 minutes vs 63. 1 ± 72. 2 minutes P <. 001), emergent procedures (28/90, 31. 1% vs 159/1293, 12. 3% P <. 001), and involvement of resident providers (36/90, 40. 0% vs 234/1293, 18. 1% P <. 001). A Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression model confirmed a statistically significant relationship between the presence of a resident provider and near-miss events (odds ratio: 2. 38 P =. 02). CONCLUSIONS: The NORA landscape is often remote in location, not as well-staffed or well-resourced, and with variable setups. With a systematic survey, we were able to capture near-miss events which would otherwise have been lost. These near-miss events cannot be evaluated in isolation. Future direction should focus on a systems-wide approach in safety surveillance that facilitates multidisciplinary collaboration and reporting. Our findings demonstrate near misses as an opportunity—to improve in-hospital access to care, promote quality assurance, and ultimately, make NORA a safer place.