Abstract
Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes. Studying those helps detect problems, which is crucial in minimizing their recurrence. We aimed to identify the frequency of peri-anesthetic critical incidents. This is a hospital-based descriptive cross-sectional study of voluntarily reported incidents, which occurred during anesthesia or following 24 hours among patients subjected to non-cardiac surgery within the calendar year 2019. Patient characteristics, anesthesia, and surgery types, category, context, and outcome of incidents were recorded in an indigenously designed form. Incidents were assigned to attributable (patient, anesthesia or surgery) factor, and were analyzed for the system,equipment or human error contribution. Altogether 464 reports were studied, which consisted of 524 incidents. Cardiovascular category comprised of 345 (65.8%) incidents. Incidents occurred in 433 (93%) otherwise healthy patients and during 258 (55.6%) spinal anesthetics. Obstetric surgery was involved in 179 (38.6%) incidents. Elective surgery and anesthesia maintenance phase included the context in 293 (63%)and 378 (72%) incidents respectively. Majority incidents 364 (69.5%) were anesthesia-attributable, with system and human error contribution in 196 (53.8%) and 152 (41.7%) cases respectively. All recovered fully except for 25 cases of mortality, which were mostly associated with patient factors, surgical urgency, and general anesthesia. Critical incidents occur even in low-risk patients during anesthesia delivery. Patient factors and emergency surgery contribute to the most serious incidents.
Highlights
Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes
This study highlights that with regular briefing and encouragement, reporting on critical incidents associated with anesthesia is feasible even in our low resource set up
Despite advances in the provision of monitoring and care, critical incidents occur during peri-anesthetic periods, mostly during the maintenance phase of anesthesia
Summary
Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes. The critical incident investigation was first used among military pilots aiming to improve their performance and safety.[3] Cooper and colleagues applied the principle in anesthesia.[4] Studying critical incidents aids formulate strategies to prevent their recurrence. This might improve anesthesia care and patient safety.[5,6] developed countries but developing countries have adopted a system to monitor and report anesthesia-related incidents.[7,8,9,10,11] no such initiatives are evident in our country
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