The statistical analysis of quality improvement system at Hamamatsu University School of Medicine for 5 years

From Ist April 1992 to 31st March 1997, at the Department of Anesthesiology and Intensive Care of Hamamatsu University School of Medicine and three af filiated hospitals, we introduced a new quality improvement system (QI syst em) based on the Las Vegas Model of the American Society of Anesthesiologis ts (ASA) to survey patients with complications related to anesthesia in the operating room and in the ward. Among a total of 24,051 cases, 690 cases (2.9% of total cases) were judged to be anesthesia-related. Complications were judged avoidable in 476 cases (69% of anesthesia-related cases). The most common incidents reported in th e operating room were complications related to the respiratory system. In t he wards nausea, vomiting, and headaches, and problems resulting from intub ation, troubles with peripheral nerves often occurred. Negative-outcome sco res range from 0 to IO points in order of severity and 604 cases (87.5%) we re in the range of 0 to 3 points, and so were light complications. A large part of the preventable errors were due to human mistakes. In the operating room, technical errors were common, whilst in the wards, a lack of the ade quate attention needed led to mistakes. In both the operating room and the ward, a lack of an alternative plan also resulted In errors. This QI system makes it possible to analyze the complications and to identi fy the causes of the complications, which will contribute to improving the quality of anesthesia.