A Prospective Analysis of Critical Incidents Attributable to Anaesthesia

Abstract

The purpose of the study was an accurate and comprehensive prospective analysis of all untoward anaesthetic events and their sequelae, within a general hospital over a period of 1 year. We identified five system sets into which each of these critical incidents could be categorised. We also recorded data pertaining to the severity of the disturbance or event, the monitor that first identified the problem and the affect, if any, of the incident upon the patient. We found a critical incident rate of 6.68%, or one in 15 anaesthetic procedures performed. By far the majority of incidents were rapidly detected and effectively managed, with a morbidity rate of only 0.53%. The application of minimum monitoring standards was strongly reinforced. The presence of an anaesthetist throughout the period of the whole anaesthetic was shown to be the most effective component of these standards. The audit identified a trend for junior anaesthetists in particular to have a higher incidence of problems with the airway and circulation and for these to be associated with increased morbidity. This prompted revised supervision and training strategies for our junior anaesthetists.

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

“…A 'wrong drug' incident occurred in 0.08%, and 0.16% had a 'wrong drug or dose' incident. 25 In our study, the drug errors represented 0.8% of all the problems we recorded. This is comparable to 1.5% by Cohen.…”

“…24 and 2.4% by Spittal. 25 Other studies, based on voluntary reporting of incidents, but without knowledge of the total number of cases, have found large variations in drug errors, from 7.2% 6 to 22% 8 of all incidents. However, as the total number of cases is not known in these studies, and the study design is different, comparison is difficult.…”

Incidence and predictors of critical events during urgent air-medical transport

“…16 The rate of 1 critical event per 12.6 hours of transit time in our study is comparable to rates in other acute care fields of medicine. 4,[17][18][19] Critical events comprised mainly hemodynamic deterioration and administration of major resuscitative procedures during transport. Procedures for airway management were frequently administered, and the rate of successful intubation we observed is consistent with rates reported in other studies.…”

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

“…[46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Several patient safety classifications were reviewed and considered for inclusion, 20,[63][64][65][66] including those developed for general practice. 7,65,[67][68][69][70] These classification systems provided considerable guidance for shaping the scope of the system needed; however, we did not judge that they would support detailed coding of patient safety incidents from general practice.…”

“…Communication with and about patients 82 (46) 463 (17) 172 (6) 1061 (38) 2805 (21) Medications and vaccines 1280 (52) 425 (17) 238 (10) 779 (31) 2484 (18) Investigative processes 536 (40) 84 (6) 38 (3) 719 (54) 1339 (10) Treatment and equipment provision 515 (68) 64 (9) 116 (15) 175 (23) 754 (6) Diagnosis and assessment 575 (79) 33 (5) 366 (50) 120 (17) 728 (5) No harm from primary care (excluded reports)…”