Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia

Abstract

Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.

Anesthesia‐related critical incidents in the perioperative period in children; a proposal for an anesthesia‐related reporting system for critical incidents in children

“…Cardiovascular incidents are the second most reported critical incidents, which is in accordance with previous studies . Hypotension and arrhythmia were the most frequent reported cardiovascular incident which is in accordance with previous recent studies .…”

“…The present study shows that the rate of anesthesia‐related critical incidents in pediatric anesthesia is substantial (3.4%) and somewhat higher than previously reported (varying between 0.6% and 3.3%) in pediatric anesthesia .…”

“…Most incidents in children involve the respiratory system (46.5%), whereas in adults, most (29.8%) incidents involve the cardiovascular system . The high incidence of complications in the respiratory tract in children has been reported before, and varies between 42 and 85/10 000 cases .…”

“…Anesthesia‐related morbidity and mortality in children has decreased over the past decades, due to the introduction of new drugs, advanced technology, and application of standards for patient monitoring during anesthesia . Critical incident reporting has proven to be an effective system to improve patient safety .…”

“…Furthermore, the type of critical incidents in pediatric patients differs from adults. Infants mostly develop critical incidents related to the respiratory system (laryngospasm, hypoxemia) and the cardiovascular system (arrhythmia) , whereas hypotension is the most commonly reported critical incident in adults. However, insight in the incidence and type of critical incidents in pediatric anesthesia is little investigated .…”