Accuracy of Vasopressor Documentation in Anesthesia Records

Abstract

Objectives: 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.

Keywords: anesthesia information management system; documentation; vasopressors.