Nurse Anesthesia continues to grow anesthesia error-reporting platform Anesthesia eNonymous
The Department of Nurse Anesthesia has relaunched Anesthesia eNonymous, a popular, secure website used to compile safety incidents and errors in operating room environments.
Years ago, nurse anesthesia chair Suzanne Wright, Ph.D., CRNA, and former 20-year chair Michael Fallacaro, D.N.S., CRNA, FAAN, saw a need for sharing stories of “what went wrong” in the operating room and how such incidents happen and could possibly be prevented in the future.
The idea stems from a three-credit course in the nurse anesthesia curriculum that explores the theoretical basis of human error, patient safety and quality assurance in anesthesia care.
“In that human factors and patient safety course, we share, collect and analyze safety incidents — either those we have witnessed or experienced, or those we have read about from elsewhere,” Wright explains. “Knowledge gained by learning from the experiences of others has in many instances shaped safer practices. So we thought, how can we find a way to get these safety-enhancing stories into the anesthesia community in a timely way?”
The original concept was to create a platform similar to the Aviation Safety Reporting System, a federally backed database that captures confidential reports from pilots and aviation professionals, analyzes the data and makes the information publicly available for review. The nurse anesthetists sought to create such a safety system for the anesthesia community, supported by the Agency for Healthcare Research and Quality, which is designed to increase the overall safety of the anesthesia work environment.
The original Anesthesia eNonymous, with the tagline “Making Patient Safety Real,” debuted in 2012 around the same time as the Make It Real Campaign for VCU. Today, AnesthesiaeNonymous.org features real stories of safety-related incidents along with lessons learned as identified by those involved in the case. Users must register, for free, to view full stories. Wright and Nickie Damico, Ph.D., CRNA, CHSE, along with other VCU nurse anesthesia faculty, present the analysis of each story.
The site ran for several years before internal IT changes resulted in the need for a more updated platform. With the help of a Richmond communications agency, website developers, a graphic designer and a photographer, the team rebuilt the site from the ground up over the course of six months in 2019.
Its original 500-plus users all received invites to the “new” Anesthesia eNonymous in April, a month after COVID-19 lockdowns began nationwide.
“It turned out to be a perfect time to relaunch a new, easier-to-use system at a moment when everyone was learning and engaging online,” Damico says.
The new site is easier for users to register, read stories and learn lessons that can ultimately save lives. The Anesthesia eNonymous of today provides “a safe community and space,” Damico says, in which providers can report on errors and incidents, and gives other practitioners a place to learn and prevent similar future occurrences. To collect stories, the site uses the software platform REDCap, or Research Electronic Data Capture. It’s a method of collecting encrypted personal information that is well-regarded in the clinical research world.
“There is no way for us to identify who submitted the incident or where it came from,” Damico says. “This is about incident reporting, learning and prevention. No anesthesia provider is perfect, and things can go wrong in even the most routine procedures.”
Wright notes that Anesthesia eNonymous serves as “a perfect complement” to the department’s continuing education division for certified registered nurse anesthetists, Nurse Anesthesiology Faculty Associates. NAFA has ramped up its online offerings and gained new users in the wake of the pandemic.