Fig. 1. Overview of the contiuous quality improvement (CQI) program. Any adverse event or adverse outcome during anesthesia care generates a CQI report. Peer review of events and outcomes (left arrows) and the role of human error (right path) is conducted for every CQI report. The symbols ( triangles , squares , circle ) in each of the five quality-indicator circles are keyed to the corresponding categories on figures 3–5 . For definitions of quality indicators, see text.