|Year : 2009 | Volume
| Issue : 4 | Page : 425-433
Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit
Sunanda Gupta1, Udita Naithani2, Saroj Kumar Brajesh3, Vikrant Singh Pathania4, Apoorva Gupta5
1 Professor, Department of Anaesthesia and Critical Care, RNT Medical College, Udaipur 313001, Rajasthan, India
2 Assistant Professor, Department of Anaesthesia and Critical Care, RNT Medical College, Udaipur 313001,Rajasthan, India
3 Medical Officer, Department of Anaesthesia and Critical Care, RNT Medical College, Udaipur 313001, Rajasthan, India
4 PG Student, Department of Anaesthesia and Critical Care, RNT Medical College, Udaipur 313001, Rajasthan, India
5 Sr.Resident, GBH American Hospital, Udaipur 313001, Rajasthan, India
|Date of Web Publication||3-Mar-2010|
26, Navratna Complex, Near Bedla Road, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Critical incident monitoring is useful in detecting new problems, identifying `near misses' and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to pen-operative critical incidents in order to develop a critical incident reporting system. W conducted a one year prospective analysis of voluntarily reported 24- hour-perioperative critical incidents, occurring in patients subjected to anaesthesia. During a one year period from December 2006 to December 2007, 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recovery in 71.42%(n=80) and mortality in 28.57% (n=32) cases. Incidents occurred maximally in 0-10 years age (23.21%), ASA 1(61.61%), in general surgery patients (43.75%), undergoing emergency surgery (52.46%) and during day time (75.89%). Incidence was more in the operating theatre (77.68%), during maintenance (32.04%) and post-operative phase (25.89%) and in patients who received general anaesthesia (75.89%). Critical incidents occurred clue to factors related to anaesthesia (42.85%), patient (37.50%) and surgery (16.96°lo). Among anaesthesia related critical incidents (42.85% n=48/112), respiratory events were maximum (66.66%) mainly at induction (37.5%) and emergence (43.75%), and factors responsible were human error (85.41%), pharmacological factors (10.41%) and equipment error (4.17%). Incidence of mortality was 22.6 per10, 000 anaesthetics (32/14,314), mostly attributable to risk factors in patient (59.38%) as compared to anaesthesia (25%) and surgery (9.38%). There were 8 anaesthesia related deaths (5.6 per 10, 000 anaesthetics) where human error (75%) attributed to lack of judgment (67.50%) was an important causative factor. We conclude that critical incident reporting system may be a valuable part of quality assurance to develop policies to prevent recurrence and enhance patient safety measures.
Keywords: Critical incidents, Critical incident reporting, Human error, Mortality, Anaesthesia related mortality
|How to cite this article:|
Gupta S, Naithani U, Brajesh SK, Pathania VS, Gupta A. Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit. Indian J Anaesth 2009;53:425-33
|How to cite this URL:|
Gupta S, Naithani U, Brajesh SK, Pathania VS, Gupta A. Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit. Indian J Anaesth [serial online] 2009 [cited 2019 Aug 20];53:425-33. Available from: http://www.ijaweb.org/text.asp?2009/53/4/425/60313
| Introduction|| |
In recent years anaesthesia, in spite of low mortality, is still associated with significant morbidity. There appears to be considerable conformity that anaesthesia risk is an important public health concern and that it is reducible  . Further, there is reason to believe that a substantive portion of that risk is related to human error resulting from errors in management or deviation from accepted practice  . If the frequency of error has to be decreased, a clearer understanding of that process is needed, the circumstances that encourage error should b e identified and the relative frequencies of different classes of errors should be established.
Since its early adoption in the field of aviation  and later in the field of anaesthesia , ; the collection o' dataon critical incidents is gaining acceptance in ana esthesia. Howeverthere are still sporadic studies ,, fron the developing countries which have tried to analyze and evaluate the frequency of critical incidents "related' to anaesthetic procedures.
Ouraim was to identifythe incidence, outcome anc potential riskfactors leadingto critical incidents durinf anaesthesia in a generaltertiaty care teaching hospital catering to mostly tribal patients and to promote volun tart' reporting of critical incidents in our department.
| Methods|| |
After obtaining approval from the hospital ethics committee, a one year prospective analysis of perioperative critical incidents was conducted in atertiary care teaching hospital situated matribalbelt from December 2006 to December 2007. Since it was an observational study without any intervention, consent from patient was not required.
In afaculty meeting of the department, it was decidedto implement 'critical incident reporting' asa quality assurance measure and anaesthesiologists were asked to report 24-hour-perioperative critical incidents, occurring in patients subjected to anaesthesia. A critical eventwas defined as "An event underanaesthesia care which had the potential to lead to substantial negative outcome (ranging from increased length ofhospital stay to death or permanent disability or cancelled operative procedure) if leftto progress",
Indigenous "Critical Incident Reporting Form" was developed and were made available in all the operation theatres, post operative wards and Intensive Care Units orHigh Dependency Units. Anaesthesiologists were regularly motivated and reminded to report critical incidents on an anonymous and voluntary basis and care was takento maintain complete confidentiality. In these forms, detailed contextual information duringrecording of an event which would enhance the subsequent review of the incident was also included.
The critical incident reporting form had two parts:
1. Description part: It was filled by anaesthesiologists who were conducting the case. Patient's age, sex, ASAgrading, previous systemic involvement, emergency elective surgery, surgical specialty, factors related to anaesthesiologist conducting the case, time, type of anaesthesia, place and phase of occurrence of critical incident, time and means of detection, type and details of systemic event and substantial negative outcome were recorded.
2. Analysis part: All completed forms of critical incidents includingmortality were reviewed and analyzed by senior consultant anaesthesiologist of the department. These critical incidents were later assigned to factors attributableto either patient or anaesthesia or surgery. When only one of these factors was responsible it was defined as "totally attributable" and ifpatient factor was associated with either anaesthesiaor surgery factor itwas defined as "partially attributable" to anaesthesia and surgery respectively. Anaesthesia related critical incidents and mortality were further analyzed for factors responsible like equipment error, pharmacological factor and human error including lackof judgment, or skill, or experience and failure to check
Data were expressed as number and proportion to calculate incidence.
| Results|| |
During the one year study period 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recovery in 80(71.42%) and mortality in 32(28.57%) cases.
Distribution of critical incidents was almost same in males and females (49.11% and 50.89% respectively) with a maximum incidence in 0-10 year age group (23.21%). Majority of critical incidents occurred in ASA grade I patients (n=69, 61.61%) as compared to ASAII (n=27, 24.11%) III (n=15, 13.39%) and IV (n=1, 0. 89%) patients. Incidence was maximum in patients with no pre-existing systemic involvement (n=69, 61.61%) followed by cardiovascular (n=19, 16.96%) and respiratory (n=8, 7.14%) involvements. Incidents were observed more between 6am to 6pm (75.89%), in emergency patients (54.46%), and in patients admitted for general surgery (43.75%), [Table 1].
Incidents occurred more frequently inpatients who received general anaesthesia (75.89%) with most of the incidents occurring in the op crating room (77.68%) or in post-operative ward (13.39%). Critical incidents occurred most commonly during the intraoperative / maintenance phase (32.04%) and frequently in the post operative period(25.89%), [Figure 1].
Majority of these incidents (98.12%) were detected by alert anaesthesiologists either clinically (38.39%) orby monitoring equipments (23.21%) or simultaneously by both (38.39%).
In our institution, resident doctors who are under training for postgraduation conduct cases under the supervision of senior consultants. Critical incidents occuied in 36 cases (32.14%) which were being conducted independently by resident doctors with less than 3 years experience. In rest of the cases resident doctors were supervised by consultants with experience of 3-5 years (n=45, 40.17%) ormore than 5 years (n=41, 27.67%). There was no indication of stress among the anaesthesiologists conducting the cases. All the incidents had occuned when the workload of the anaesthesiologist was less than 12 hours, without any report of contrabuting factors like haste, distraction or in adequate help. Most of the critical incidents were due to events involving eitherresp iratory system (39.29%), or cardiovascular system (32.14%) or both (9.82%), [Table 2].
From a total of 112 reported critical incidents, cardiac arrest occurred in 41 cases (36.6%, 29 per 10,000 anaesthetics) out of which 9 cases (8.03%) recovered completely and 32(28.57%) had a fatal outcome (22.6per 10,000 anaesthetics). The occurrence of critical incidents led to postponement of surgeiy in only 2 cases: one occurred during induction of anaesthesia (7-year-male child posted for herniotomy under general anaesthesia had hypoxia and bradycardia during induction leading to cardiac arrest but was resuscitated with full recovery) and the other occurred duringpronepositioning of the patient (57yearold male posted for lumbar laminectomy had paroxysmal supraventricular tachycardia with hypotension that responded to esmolol).
Critical incidents and mortality were correlated with factors attributable to either patient or anaesthesia or surgery. [Table 3] shows that out of 112 critical incidents maximum incidents (42.86%, n=48) were related to anaesthesia factor [Totally attributable in 40.18% (n=45) and partially attributable in 2.68% (n=3)], followed closely by patient factor (37.5%, n=42). On the contrary, out of 32 mortalities 59.38%, (n=19) were due to patient's pre-existing condition. Anaesthesia factorwas responsible for 25% (n=8) mortalities [Totally attributable 18.75% (n=6); partially attributable 6.25% (n=2)]. Respiratory events were responsible for most of the anaesthesia related critical incidents (n=32/48, 66.66%) and mortality (n=4/8,50%), [Table 4]. Human error was the most common responsible factor for anaesthesia related critical incidents (n=41/48,85.41%) and mortality (n=6/ 8,75%), while equipment error and pharmacologic factor were less common factors responsible, [Table 5] and [Table 6].
| Discussion|| |
Internal audits based on recording ofcritical incidents in institutions are imperative forthe speciality of anaesthesia, firstly, to study the changes in patient outcome which underline the improvement in standards of anaesthesia care and secondly, for sharing and discussingthese critical incidents to evolve new policies to prevent recurrences , ,
Many variables (patient status, surgical procedure, and surgical expertise) make the delineation of anaesthesia related factors obscure. The relative rarity of adverse outcome makes it imperative to study large number of patients overtime. The methods used to collect information about safety of anaesthesia and to establish the risk factors have included peer reviews, hospital audit, reports to medical defense societies  , retrospective  and prospective studies  . A prospective reporting system avoids the problems of inaccurate recall and allows warnings and advice to be issued 'necessary, soon afterthe occurrence  . In ourinstitution we conducted a prospective survey of 24-hour perioperative critical incidents over a one year period and found 112 critical incidents with over all incidence of 0.79% of which 0.33% (n=48) were attributable to anaesthesia. The frequency of incidents reported from different institutions have varied from 0.28% to 2.8% , while higher incidence of 12.1%  and 10.6%  have also been reported. The vast difference in these figures lies in the fact that interpretation of critically ill in anaesthesia varies according to individual perception of an incident and to an ambiguity in how these are applied in practice. There is reluctance to report seemingly minor events while some major events go unreported for fear of retribution, lack of motivation and lack of acceptance of the fact that it could be beneficial as an educational tool  .
Recent studies define mortality associated with anaesthesia as death under, as a result of, orwithin 24 hour of an anaesthetic , . In literature, crude anaesthetic mortality(i.e. combined anaesthetic and surgical mortality) associated with anaesthesia ranges between 10-30 per 10,000 anaesthetics,,.It has been suggested that anaesthesia related mortality has decreased in the last three decades and currently ranges from 0.05 to 10 per 10,000,,and in most developed countries lies between 0.12-1.4 per 10,000 anaesthetics.
In our audit, crude anaesthetic mortality was 22.6 per 10,000 and anaesthesia related mortality was 5.6 per 10,000 anaesthetics. The reasons forhigher mortality rate in our audit as compared to developed countries may be due to the fact that we do not have an effective primary and secondary health care system in our country, resulting in tertiary care hospitals like ours dealing with more poorly optimized, sicker patients. Anaesthesia related mortality figures may well be different in the developing countries where only limited trained work force, monitoring and training facilities are available,.
Independent predictors of operative mortality cited in literature include advanced and pediatric (less than 1 year) age group as well as male gender,. We found no correlation between sex and occurrence of critical incidents ormortalities. There was no association of mortality with age however maximum critical incidents occurred in 0-10 year age group, which shows that the paediatric population are always at risk of anaesthesia because of anatomical and physiological reasons,, .
In our audit, incidence of critical incidents and mortalities was maximum in ASAl and II patients, as maximum surgical patients belonged to this physical status. In higher AS A physical status senior consultant attendance, stringent monitoring and extravigilance could be areason for less incidence6,,.Though some authors have found a clearrelationship between increasing ASA grade and the risk of critic al incidents particularly physiological incidents  and mortality,.
There has been a slightly higher incidence of critical incidents  and mortalities,, in emergency surgery as compared to elective surgery. Poor optimization of patient's pre-op erative status, non-availability of equipments, emergency drugs, investigation facilitiesand poor operating conditions are all contributory factors in emergency situation in the developing countries.
Critical incidents mostly occurred during the day time  coinciding with peak working hours in our institution. However it could be argued that compliance with reporting is low at late hours. General surgery patients were found more vulnerable to occurrence ofcritical incidents which may be due to more number ofpatients operated under general surgery, more chance of fluid and electrolyte imbalance and sepsis in these patients ,
We found in common with others that the frequency of critical incidents and mortality was higher with general than neuraxial anaesthesia,, . However this may be because many high risk surgeries are performed under general anaesthesia nncludungcardiac, thoracic and neumsurgicalprocedures. Likewise there may be abias towards general anaesthesia in emergency settings or in patients with co-existing medical conditions. The most comprehensive recent survey of cardiac arrest incidence during neuraxial anaesthesia reported as 2.7 per 10,000 anaesthetics  is nearly similarto our study (3.4 per 10, 000).Impmved knowledge of neuraxial block physiology and the use of new local anaesthetics with fewer side effects, associated with more routinely used oxygen monitoring through pulse oximetty has substantially decreasedthe possibility of major complications during neuraxial anaesthesia.
We found no correlation between occurrence of critical incidents and mortalities and experience level of anaesthesiologist , . It has been shownthatfatigue adversely affects the professional performance of anaesthetists  . Since our resident doctors have approximately an 8 hourly work schedule with an average work force of 1-2 anaesthesiologist per case, there were no reports of stress , haste, inattention, fatigue or inadequate help as reported by other workers , .
Operating room was observed as a vulnerable site for occurrence of critical incidents , . Induction and maintenance phase have been considered as "incident rich phase" , but we found a higher incidence in the maintenance and post-operative phase, probably the latter could be attributable to the inadequate postoperative monitoringand care available in our institution. However anaesthesia related incidents occurred maximally during emergence and induction which are similarly other studies ,, .
Critical incidents related to airway management have been found in 17-34% of incidents , and airway management has been shownto contribute to approximately one quarter of anaesthesia related deaths ,, . In our auditrespiratory causes were more frequently responsible for anaesthesia related critical incidents and mortality was mainly due to laryngospasm, hypoxia, esophageal intubation, bronchospasm and aspiration.
All anaesthesiologists aspire to an anaesthesia "system" that is completely safe. However, any system operated by human beings is subjectto human failure; this is both normal and inevitable  . Because patterns ofhuman errorin anaesthesiaas elsewhere, are identifiable predictable and repetitive, they lend themselves to classification and analysis  . From such analysis we gain a clearer understanding of how anaesthetists behave, which is an important step in the logical evaluation of strategies to make such failures less common.
In our audit human error has been implicated as the major cause of anaesthesia related critical incidents ,,,,, and mortality , . Lack ofjudgment or experience, skilland failureto checkwere the most frequently reported factors for human errors. Thus there are elements of human error in majority of anaesthesia related critical incidents and mortalities, although the majority of such failures were recognized and intercepted before they led to an adverse outcome. It is known that the basis for all accidents or nearaccidents in any situation is unsafe practice orworking condition  .
There may have been some methodological weakness associated with our study. Firstly, under-reporting since itwas based on adverse events being voluntarily reported by faculty and residents and it seems that the anaesthesiologists report major adverse events more accurately andfrequently ratherthan minor events. Secondly critical incidents reported in this study over a one year period represent only a proportion of all mishaps that occurin association with anaesthesia resulting in avert' small sample size to calculate statistical significance of risk factors.
To conclude, anaesthesia continues to be associated with mortality and morbidity despite improvements nl drugs and equipments. Human error is the most important factor in the majority of these incidents. We emphasize that strategies and protocols should be developed for increasing and updatingknowledge base to avoid errors of judgment. There is evidence that the use of checklists, protocols and unproved awareness of the relevance of critical incidents can improve safety  . Thus critical incidentreporting should be introduced in all anaesthesia departments as partof quality assurance programs to ensure improved patient care.
| References|| |
|1.||Philips OC, Capizzi LS. Anaesthesia mortality. Clin Anaesth 1974;10:220-224. |
|2.||Goldstein A Jr, Keats AS. The risk of anaesthesia. Anesthesio 11970;33 : 130-143. |
|3.||Flanagan JC The critical incident technique. Psychol Bulletin 1954;51: 397-358. |
|4.||Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anaesthesia mishaps. A study of human factors. Anesthesiol 1978;49:339-406. |
|5.||Cooper JB, Newbower RS and Kitz RI. An analysis of maj or errors and equipment failures in anaesthesia management: Considerations for prevention and detection. Anesthesio11984;60:34-42. |
|6.||Khan PA and Hoda MQ . Aprospective survey of intraoperative critical incidents in a teaching hospital in a developing country. Anaesth200l ; 50: 171-182. |
|7.||Manghnani PK, Shinde VS and Chaudhari LS . Critical incidents during anaesthesia `An Audit'. Ind j Anaesth 2004;48:287-294. |
|8.||Ajaj H. and Pansalovich E. "How safe is anaesthesia in Libya"? The Internet Journal ofHealth 2005;4:1-4. |
|9.||Webb RK, Currie M and Morgan CA The Australian Incident monitoring study : An Analysis of 2000 incident reports. Anaesthlntens Care 1993;21:520-528. |
|10.||Van der Schaaf TW Medical applications of industrial safety science. Qua! Saf Health Care 2002;11:205-6. |
|11.||Runciman WB, Edmonds MJ, Pradhan M Setting priorities for patient safety. Qual Saf Health Care 2002;11:224-9. |
|12.||Runciman WB. Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system-is this the right model?Qual Saf Health Care 2002;1 1:246-51. |
|13.||Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu Av, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med 2003 31:1006-11. |
|14.||Utting JE, Gray TC, Shelley FC . Human misadventure in anaesthesia. Can Anaesth Soc J 1979 ; 26:472-8. |
|15.||Craig J and Wilson ME. A survey of anaesthetic misadventures. Anaesth 1981 36:933-936. |
|16.||Kumar \ Barcelos WA, Mehta MP, CarterJG An analysis of critical incidents in a teaching departm ent for quality assurance. Anaesthesia 1988;43:879-83. |
|17.||Galletly DC, Mushet NN. Anaesthesia system errors. Anaesthesia andlntensive Care 1991;19:66-73. |
|18.||Maaloe R, Cour M, Hansen A, et al. Scrutinizing incident reporting in anaesthesia : why is an incident perceived as critical? Acta Anaesthesiol Scand 2006;50:1005-1013. |
|19.||Marsh, Peter G and William DB, et al. Asurveyof 112,000 anaesthetics in one teaching hospital (1975-83). Can Anaesth Soc J 1986:33:22-31. |
|20.||Short TG, O'Regan A, Jayasuriya JP, Rowbottom M Buckley TA, Oh TB. Improvements in anaesthetic care resulting from critical incident reporting programme. Anaesthesia 1996;51:615-21. |
|21.||Tiret L, Desmonts JIM, Hatton F, Uourc'h G Complications associated with anaesthesia: a prospective surveyinfrance. CanAnaesth Soc J 1986;33:336-334. |
|22.||Warden JC, Borton CL, Horan BF. Mortality associated with anaesthesia in NSW 1984-1990. Medical Journal of Australia 1994;161:585-593. |
|23.||HarrisonGG: Death due to anaesthesia at Groote Schuur Hospital, Cape Town 1956-87. Part 1. Incidence. South African Medical Journal 1990;77:412-415. |
|24.||Lunn IN, Devlin HB. Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet 1987;2:1384-1386. |
|25.||HarrisonGG Deathdue to anaesthesia in Groote Schuur hospital, Cape Town 1956-87. Part II. Causes and changes in aetiological pattern of anaesthetic-contributorydeath SAfr Med J 1990;77:416-421. |
|26.||Eichhorn-JH. Prevention of intraoperative anaesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572-577. |
|27.||Cohen MM, Duncan PG Tweed WA, et al. The Canadian four-centre study of anaesthetic outcomes:I. Description of methods and populations. Can J Anaesth 199239:420-429. |
|28.||Braz LG, Modolo NSP and Mascimento P, et al. Perioperative cardiac arrest: a study of 53,718 anaesthetics over 9 years from a Brazilian teaching hospital. Br J Anaesth 2006;95 :569-75. |
|29.||Mckenzie AG Mortality associated with anaesthesia at Zimbabwean teaching hospitals. S Mr Med J 1996; 86: 338-342. |
|30.||Newland MC, Ellis SJ, Lydiatt CA, et al. Anaesthetic related cardiacarrest and its mortality: a report covering 72,959 anaesthetics over 10 years from a US teaching hospital. Anesthesiology 2002 97:108-15. |
|31.||Sprung J, WamerME, Contreras MG, et al. Predictors of survival following cardiac arrest in patients undergoing non-cardiac surgery: a study of 518,294 patients at a tertiary referral center. Anesthesiology 2003 ;99:259-69. |
|32.||Currie M. A prospective survey of anaesthetic critical events in a teaching hospital. Anaesth Intens Care 1989;17:403.411. |
|33.||Arbous MS, Grobbee DE, et al. Mortality associated with anaesthesia: A qualitative analysis to identify risk factors. Anaesth200l; 5:1141-1153. |
|34.||Gravenstein JS, Cooper JB, Orkin FK. Work and rest cycles in anaesthesia practice. Anesthesiology 1990;72:737-742. |
|35.||Williamson JA, Webb RK, SellenA, et al. Human failure: An analysis of 2000 incidents reports. Anaesth Intens Care 1993;21:678-683. |
|36.||Short TG O'regan A, Lew J, OH TB. Critical incident reporting in an anaesthetic department assurance programme. Anaesthesia 1993;48:3-7. |
|37.||Russell WI, WebbRK, UanDer Wilt JH, RuncimanWB. The Australian Incident Monitoring Study. Problems with ventilation: an analysis of 2000 incident reports. AnaesthlntensiveCare 1993 ;21:617-620. |
|38.||Allnutt MF. Human factors in accidents. Br J Anaesth 198759:856-864. |
|39.||Runciman WB, SellenA, Webb RK, et al. Errors, incidents and accidents in anaesthetic practice. Anaesth Intens Care 1993;21:506-519. |
|40.||Liu EHC and Koh KF. A prospective audit of critical incidents in anaesthesia in a university teaching hospital: AnnAcadMed Singapore 2003;32:814-20. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]