Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore

Tay, Chin Lin; Tan, GH; Ng, Siok‐Bian

doi:10.1046/j.1460-9592.2001.00767.x

Cited by 184 publications

(184 citation statements)

References 29 publications

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“…Approximately 11.3% of our incidents were equipment related. This was lower compared to Vander Walt et al who reported 14% which is nearer to our report but contrary to Tay's report of 4.4% equipment related incidents [9] [13].…”

Section: Discussioncontrasting

confidence: 99%

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

Abbasi¹

2017

OJOG

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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.

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Section: Discussioncontrasting

confidence: 99%

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

Abbasi¹

2017

OJOG

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“…13,14 The incidence of critical events in general paediatric anaesthesia is documented to be 8.6% in infants which improves to 2.1% in older patients with a statistically significant difference in children < 10 kg. 2 Murat 11 reiterated that intraoperative adverse events were more likely in infants < 12 months.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Due to their peculiar paediatric airway, they are prone to difficult airway management and laryngoscopy as well as other airway complications. Bordet 3 demonstrated that airway complications occurred in 7.87% of children under anaesthesia and that the incidence varied with the type of airway device used with laryngeal mask airway(LMA) having the highest incidence of 10.2%, tracheal tube 7.4% and facemask 4.7%.…”

Section: Introductionmentioning

confidence: 99%

Airway and respiratory complications in children undergoing cleft lip and palate repair

Desalu¹,

Adeyemo²,

Akintimoye³

et al. 2011

Ghana Medical Journal

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“…2,4,14,23 In developed countries, the perioperative mortality rate is 0.42-6.8 per 10,000 anesthetics. 14 Most of the fatalities are associated with airway or cardiocirculatory events.…”

Section: Anesthesiological Complicationsmentioning

confidence: 99%

Intraoperative complications in pediatric neurosurgery: review of 1807 cases

Lindert¹,

Arts

Blok

et al. 2016

PED

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OBJECTIVE Minimal literature exists on the intraoperative complication rate of pediatric neurosurgical procedures with respect to both surgical and anesthesiological complications. The aim of this study, therefore, was to establish intraoperative complication rates to provide patients and parents with information on which to base their informed consent and to establish a baseline for further targeted improvement of pediatric neurosurgical care. METHODS A clinical complication registration database comprising a consecutive cohort of all pediatric neurosurgical procedures carried out in a general neurosurgical department from January 1, 2004, until July 1, 2012, was analyzed. During the study period, 1807 procedures were performed on patients below the age of 17 years. RESULTS Sixty-four intraoperative complications occurred in 62 patients (3.5% of procedures). Intraoperative mortality was 0.17% (n = 3). Seventy-eight percent of the complications (n = 50) were related to the neurosurgical procedures, whereas 22% (n = 14) were due to anesthesiology. The highest intraoperative complication rates were for cerebrovascular surgery (7.7%) and tumor surgery (7.4%). The most frequently occurring complications were cerebrovascular complications (33%). CONCLUSIONS Intraoperative complications are not exceptional during pediatric neurosurgical procedures. Awareness of these complications is the first step in preventing them.

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Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore

Abstract: Future reviews of a larger patient population may be helpful to determine trends of perioperative events and whether quality assurance programs have made a difference.

Cited by 184 publications

References 29 publications

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

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

Airway and respiratory complications in children undergoing cleft lip and palate repair

Intraoperative complications in pediatric neurosurgery: review of 1807 cases

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