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CLINICAL INVESTIGATION
Year : 2009  |  Volume : 53  |  Issue : 4  |  Page : 425-433

Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit


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

Correspondence Address:
Sunanda Gupta
26, Navratna Complex, Near Bedla Road, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640204

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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.


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