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Developed by: Committee on Patient Safety and Education
Original Approval: October 15, 2025
Introduction
Adverse and near-miss events may occur in the perioperative space. An adverse event is defined as an occurrence in which care resulted in an undesirable clinical outcome, not solely related to the patient’s underlying disease. A near-miss, on the other hand, is an event that had the potential to cause harm but failed to do so due to chance, prevention, or mitigation. Adverse and near-miss event review is critical to identify modifiable causes to prevent event recurrence, encourage further reporting, and promote safety culture. The purpose of this statement is to outline best practices in the adverse event analysis process.
Reporting Adverse Events
The first step is event reporting. Departments may select a combination of self-reporting and automated reporting to ease the burden of reporting and maximally capture reports of all adverse events and near misses in a timely manner. Staff should be educated on their local reporting system and on which events to report. A strong safety culture should encourage reporting without fear of retribution. Some reporting channels, such as national registries (e.g., Anesthesia Incident Reporting System [AIRS]) and Patient Safety Organizations (PSOs) ensure confidentiality for the reporting staff to encourage transparency and capture of all adverse events. Analysis teams should be wary of misuse of the reporting system for weaponized reporting and should educate clinicians against using the system for this purpose.
Analysis of Adverse Events
The analysis process should ideally be standardized and regularly occur. Analysis could include a broad categorization of the event, a harm score, and a systematic evaluation of contributing factors. Referrals to other departments should be considered when appropriate. The clinician(s)’ performance should be evaluated within a just culture framework, and when possible, systems solutions should be proposed to prevent event recurrence. The analysis process should conclude with clear follow-up action items and responsible individuals.
Disclosure, Feedback, and Follow-up
Disclosure of the event to patient(s) and family members may occur at the time of the event and possibly after the analysis process with an update on conclusions and actions taken. Feedback should be given to the clinicians who were involved in the adverse event. The lessons learned should be shared with the entire department for educational purposes. The event and actionable items should be shared with hospital quality and safety leadership for consideration of necessary reporting to outside agencies such as medical boards and/or the Department of Public Health.
The entire process of adverse event analysis, from event reporting through disclosure, should maintain confidentiality under organizational bylaws and policies, including possible protections from legal discovery (which may vary by state). Data related to the event and subsequent analyses and/or discussions should be stored in secure databases.
Other Considerations
Consideration should be given to the second victim effect, providing peer support for the involved clinician(s) who may be traumatized by the event.
Please refer to the ASA Committee Resource on Adverse Event Analysis for a broader discussion.
Other Statements of Interest:
References:
Curated by: Governance
Last updated by: Governance
Date of last update: October 15, 2025
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