Review of critical incidents in a university department of anaesthesia.
In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
T
T
Saito
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
Z W
ZW
Wong
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
K K
KK
Thinn
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
K H
KH
Poon
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
E
E
Liu
D000776:Anesthesiology / Q000379:methods / Q000706:statistics & numerical data*; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D008485:Medical Audit / Q000379:methods* / Q000706:statistics & numerical data*; D019300:Medical Errors / Q000706:statistics & numerical data; D061214:Patient Safety / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000706:statistics & numerical data*; D012307:Risk Factors; D012308:Risk Management / Q000379:methods / Q000706:statistics & numerical data*; D012846:Singapore
audit; critical incidents; human factors; patient safety