An analysis of critical incidents in a teaching department for quality assurance A survey of mishaps during anaesthesia

Kumar, Viney; Barcellos, W. A.; Mehta, M. P.; Carter, J.G.

doi:10.1111/j.1365-2044.1988.tb05606.x

Cited by 81 publications

(23 citation statements)

References 6 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[35][36][37][38][39][40][41][42] This partly reflects the role of actual equipment failure, reported to occur in 15-20% of the procedures, but probably also refers to overall quality of care.…”

Section: Discussionmentioning

confidence: 99%

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

et al. 2005

View full text Add to dashboard Cite

This article and its accompanying editorial have been selected for the Anesthesiology CME Program. After reading both articles, go to http://www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue.Background: Quantitative estimates of how anesthesia management impacts perioperative morbidity and mortality are limited. The authors performed a study to identify risk factors related to anesthesia management for 24-h postoperative severe morbidity and mortality.Methods: A case-control study was performed of all patients undergoing anesthesia (1995-1997). Cases were patients who either remained comatose or died during or within 24 h of undergoing anesthesia. Controls were patients who neither remained comatose nor died during or within 24 hours of undergoing anesthesia. Data were collected by means of a questionnaire, the anesthesia and recovery form. Odds ratios were calculated for risk factors, adjusted for confounders.Results: The cohort comprised 869,483 patients; 807 cases and 883 controls were analyzed. The incidence of 24-h postoperative death was 8.8 (95% confidence interval, 8.2-9.5) per 10,000 anesthetics. The incidence of coma was 0.5 (95% confi-

show abstract

Section: Discussionmentioning

confidence: 99%

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

et al. 2005

View full text Add to dashboard Cite

show abstract

“…The Association of Anaesthetists of Great Britain and Ireland produces a checklist for anesthetic equipment (13), and following a number of deaths from blocked anesthetic tubing (14) there can now be few excuses for not performing a machine and breathing circuit check. Kumar et al (15) achieved a 62% reduction in checking error by the provision of checklists, and we plan to wall mount a flip chart containing our department's routine and emergency checklists in all anesthetic locations so that these are visible and immediately available. Most of the airway incidents in this category were because of endobronchial intubation, or to endobronchial movement of a tracheal tube on positioning the patient for surgery.…”

Section: Discussionmentioning

confidence: 99%

Human factors in pediatric anesthesia incidents

Marcus

2005

Pediatric Anesthesia

View full text Add to dashboard Cite

show abstract

“…The frequency of incidents reported from individual institutions has varied from 0.28% to 3.5% [8]- [13] while higher incidences of up to 12.1% [14] have also been reported. The difference in figures may be due to the variation in definitions of critical incidents and lack of accepted nomenclature [15] as well as individual perception and ambiguity in application.…”

Section: Discussionmentioning

confidence: 99%

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Zeng¹,

Ng²,

Thong³

2016

IJCM

View full text Add to dashboard Cite

Introduction: Critical incident monitoring is important in quality improvement as it identifies potential risks to patients by analyzing adverse events or near-misses. Methods: This study analyses the reported incidents in a tertiary hospital over a 4-year period. Results: A total of 441 incidents were reported out of 98,502 anesthetics performed during the study period. Of these incidents, 67 resulted in no harm caused, 116 with unanticipated ICU admissions and 20 mortalities. The odds of having a critical incident increased with ASA status: from an odds ratio of 2.08 (95% CI: 1.58 to 2.74) for ASA 2 patients compared to ASA1, to OR of 13.70 (5.91 to 31.74) in ASA 5 compared to ASA 1. Critical incidents also have higher odds occurring out of hours (OR 1.7 (1.45 to 2.23) compared to daytime hours (08:00-17:00). They occurred most commonly in maintenance phase (142, 32.7%), followed by induction (120, 27.6%). The most common types of incidents include airway and respiratory (110, 24.9%) followed by drug related incidents (67, 15.2%). Human error was attributed as a significant contributing factor in 276 incidents (61.5%) followed by patient factors in 112 incidents (25.4%). Mitigating factors such as vigilance by staff involved were significant in 136 incidents (30.3%). Conclusion: Higher ASA status appears to be the most important factor associated with actual or potential patient harm in our study. Also significant, was time of incident, with incidents more likely out of hours. Critical incident reporting is a valuable part of quality assurance. We should continue to invest in incident reporting, incident analysis and improvement plans.

show abstract

An analysis of critical incidents in a teaching department for quality assurance A survey of mishaps during anaesthesia

Cited by 81 publications

References 6 publications

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

Human factors in pediatric anesthesia incidents

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Contact Info

Product

Resources

About