Table 1 .

Sample Non-routine Events (NRE) Elicited from Clinicians in the Post-Anesthesia Care Unit

Procedure: Non-Routine Event(s) Brief Description

Knee arthroscopy: Surgeon took 3 times longer than expected and prolonged tourniquet time adversely affected the patient’s blood pressure. Allograft neck/face burn: Unable to monitor ventilation during case because expired gas monitoring line inadvertently clamped in the surgical drapes. Parotidectomy: Patient movement during surgery despite perceived adequate depth of anesthesia. No muscle relaxant administered at surgeon request. Repair distal tibia fracture: a) Patient moved during laryngoscopy. Provider admitted he was unfamiliar with muscle relaxant used and waited insufficient time prior to laryngoscopy; b) Failure of anesthetic agent analyzer requiring its intraoperative replacement. Laparoscopic cholecystectomy: Slow to detect obese patient slipping off OR bed because patient’s body was largely obscured by surgical drapes in a darkened room. Repair mandible fracture: Patient was induced with general anesthesia and was difficult intubation but surgeons unavailable for >1 hr. Previous 2-hr delay of case start led surgeons to leave hospital without notifying anyone. Tonsillectomy: Unanticipated difficult pediatric airway and failed intubation—multiple attempts associated with substantial coughing and laryngospasm. Attending not immediately available.