Accuracy of Vasopressor Documentation in Anesthesia Records

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• 作者：David B. Wax ; MD^* ; ^{david.wax@mssm.edu" class="auth_mail" title="E-mail the corresponding author} ; Justin B. Feit ; BA^&dagger ;
• 关键词：anesthesia information management system ; vasopressors ; documentation
• 刊名：Journal of Cardiothoracic and Vascular Anesthesia
• 出版年：2016
• 出版时间：June 2016
• 年：2016
• 卷：30
• 期：3
• 页码：656-658
• 全文大小：177 K

文摘

To determine the accuracy of documentation of vasoactive medication administration in anesthetic records.

Design

Cross-sectional observational study.

Setting

Single academic center.

Participants

Attending and resident anesthesiologists.

Interventions

None.

Measurements and Main Results

An auditor inspected the anesthesia worktop between cases looking for partially used syringes of vasopressors, and the anesthesia record for the preceding case was reviewed for entries related to administration of these agents. In 100 anesthesia records for cases in which a phenylephrine and/or ephedrine bolus was apparently administered, 26% (95% CI: 18-35%) had full documentation and 36% (95% CI: 27-46%) had no documentation. In the 38% of cases that had partial documentation, a median of 50% (interquartile range 33%, 67%) of the total amounts given were documented.

Conclusions

The authors found complete or partial omission of documentation of bolus doses of vasopressors in anesthesia records in the majority of cases in which such drugs were given. This finding has the potential to jeopardize the data integrity of local and pooled case registries and conclusions of retrospective studies that utilize these data.