Critical Incident Reported in an Obstetric Unit of a Tertiary Care Hospital of a Developing Country, over a Period of Two Years

Abstract

Introduction: A lot of literature is available on critical incidents and near misses but specialty based critical incidents are very scanty. Aim: In this audit, we aimed to report critical incident and near misses during conduct of obstetric anesthesia over a period of two years. Methodology: Critical incident forms were collected, entered, analyzed and categorized on the basis of American Standards Association (ASA), phase of incidents, system involved, and type of errors, outcome and action taken. Human error was further categorized on the basis of their contributing factor marked in form. Results: During the reporting period, 5511 anaesthetics were administered and 55 reports were received out of which 53 reports were included in analysis. Fifty three reports were divided into 33 critical incidents and 20 near misses. Out of 33 critical incidents, 54.5% involved CVS system and musculoskeletal system, followed by neuromuscular (n = 5), drug related (n = 4), airway/respiratory system (n = 2), central nervous system (n = 2) and renal system (n = 1). Forty five incidents possess no untoward effect while 7 led to minor and only one to severe physiological disturbance. Human errors were (n = 30) 57% reports and failure to check was the main contributory factor. Conclusion: Critical incidents reporting needs to be introduced in sub-specialties at departmental, national and international level. Checking of equipment, medication and anesthesia machine must be part of regular checks in elective and emergency cases.