title: Incident reporting by acute pain service at a tertiary care university hospital.
abstract: OBJECTIVE
  Provision of effective and safe postoperative pain management is the principal responsibility of acute pain services (APSs). Continuous quality assurance is essential for high-quality patient care. We initiated anonymous reporting of critical incidents by APS to ensure continuous quality improvement and here present prospectively collected data on the reported incidents. Our objective was to analyze the frequency and nature of incidents and to see if any harm was caused to patients.
  
  
  METHODS
  Data were collected from January 1, 2012 to September 30, 2013. An incident related to pain management was defined as An incident that occurs in a patient receiving pain management supervised by APS, and causes or has the potential to cause harm or affects patient safety. A form was filled including incident type, personnel involved, any harm caused, and steps taken to rectify it. Frequencies and percentages were computed for categorical variables.
  
  
  RESULTS
  A total of 2042 patients were seen and 442 (21.64%) incidents reported during the study period, including documentation errors (136/31%), noncompliance with protocols (113/25.56%), wrong combination of drugs (56/12.66%), premature discontinuation (74/16.72%), prolonged delays in change of syringes (27/6.10%), loss to follow-up (19/4.29%), administration of contraindicated drugs (9/2.03%), catheter pull-outs (6/1.35%), and faulty equipment (2/0.45%). Steps were taken to rectify the errors accordingly. No harm was caused to any patient.
  
  
  CONCLUSIONS
  Reporting of untoward incidents and their regular analysis by APS is recommended to ensure high-quality patient care and to provide guidance in making teaching strategies and guidelines to improve patient safety.
authors.affiliation: Department of Anesthesiology, Aga Khan University, Karachi, Pakistan.
authors.forename: Aliya
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Department of Anesthesiology, Aga Khan University, Karachi, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Yasir
keywords: Pain management; patient safety; postoperative pain; quality improvement