An Analysis of Quality Assurance Events in Nonoperating Room Anesthetizing Locations: A Qualitative Retrospective Cohort Study
Authors' conclusion
This large qualitative study characterized NORA QA events across multiple dimensions. Our findings highlight that QA events in NORA are complex and often due to a combination of factors, underscoring both clinical and systems-level vulnerabilities.
Study context
- Population
- Adult nonoperating room anesthesia (NORA) cases at a large academic health system, August 1, 2018 to December 31, 2022Quality assurance (QA) report comments analyzed
- Participants
- 984 participants
- Outcome
- Characterization of NORA quality assurance (QA) events
Methodological detailstwo-center, deductive and inductive coding, System Engineering Initiative for Patient Safety (SEIPS) framework, QA event reporting mandatory for every anesthetic
- Two-center
- Deductive and inductive coding
- SEIPS framework
- QA event reporting mandatory for every anesthetic
Main finding
As reported in the abstract
NORA QA event characteristics
NORA cases among all cases
106,476
21.4%
Observational data: associations, not effects.
Original publication
An Analysis of Quality Assurance Events in Nonoperating Room Anesthetizing Locations: A Qualitative Retrospective Cohort Study. Anesth Analg. Published 7 July 2026. doi:10.
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