title: Reporting critical incidents in a tertiary hospital: a historical cohort study of 110,310 procedures.
abstract: OBJECTIVE
  Investigation of adverse events associated with anesthetic procedures is a method of quality control that identifies topics to improve clinical care and patient safety. Most research to date has been based on closed claim registries and anonymous reports which have specific limitations. Therefore, to evaluate a hospital's reporting system, the present study was designed to describe critical incidents that anesthesiologists voluntarily and non-anonymously reported through an anesthesia information management system.
  
  
  METHODS
  This is a historical observational cohort study on patients (age > 18 yr) undergoing anesthetic procedures in a tertiary referral hospital. A 20-item list of complications, as developed by the Netherlands Society of Anesthesiologists, was prospectively completed for each procedure. All critical incidents registered in the anesthesia information management system were then reclassified into 95 different critical incidents in a reproducible way.
  
  
  RESULTS
  There were 110,310 procedures performed in 65,985 patients, and after excluding 158 reports that did not depict a critical incident, 3,904 critical incidents in 3,807 (3.5%) anesthetic procedures remained. Technical difficulties with regional anesthesia (n = 445; 40 per 10,000 anesthetics; 95% confidence interval [CI], 36 to 44), hypotension (n = 432; 39 per 10,000 anesthetics; 95% CI, 35 to 43), and unexpected difficult intubation (n = 216; 20 per 10,000 anesthetics; 95% CI, 18 to 23) were the most frequently documented critical incidents.
  
  
  CONCLUSIONS
  Accurate measurement and monitoring of critical incidents is crucial for patient safety. Despite the risk of underreporting and probable misclassification of manual reporting systems, our results give a comprehensive overview on the occurrence of voluntarily reported anesthesia-related critical incidents. This overview can direct development of a new reporting system and preventive strategies to decrease the future occurrence of critical incidents.
authors.affiliation: Department of Anesthesia, University Medical Center Utrecht, Local Mail Stop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
authors.forename: Karin E
authors.initials: KE
authors.lastname: Munting
authors.affiliation: Department of Anesthesia, University Medical Center Utrecht, Local Mail Stop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
authors.forename: Bas
authors.initials: B
authors.lastname: van Zaane
authors.affiliation: Department of Anesthesia, University Medical Center Utrecht, Local Mail Stop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
authors.forename: Antonius N J
authors.initials: AN
authors.lastname: Schouten
authors.affiliation: Department of Anesthesia, University Medical Center Utrecht, Local Mail Stop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
authors.forename: Leo
authors.initials: L
authors.lastname: van Wolfswinkel
authors.affiliation: Department of Anesthesia, University Medical Center Utrecht, Local Mail Stop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, The Netherlands. j.c.degraaff-2@umcutrecht.nl.
authors.forename: Jurgen C
authors.initials: JC
authors.lastname: de Graaff
mesh_terms: D000328:Adult; D016907:Adverse Drug Reaction Reporting Systems; D000368:Aged; D000758:Anesthesia / Q000009:adverse effects*; D000776:Anesthesiology / Q000379:methods*; D000777:Anesthetics / Q000009:adverse effects*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011446:Prospective Studies; D062606:Tertiary Care Centers
chemical_list: D000777:Anesthetics