Incident Related to Anesthesia at Tertiary Care University Hospital
Keywords:
critical anesthesia incidents; morbidity; mortality; perioperative complications; risk managementAbstract
Objectives: The purpose of this study was to detect critical incidents involving anesthesia over a one-year period. We identified the magnitude of each incident, factors leading to that incident, and how it could have been prevented.
Methods: A prospective, descriptive study was conducted between February 2015 and January 2016. A standard incident report form was completed for every critical anesthesia incident occurred; these reports were then audited.
Results: From among the 19,163 cases of anesthesia, there were 236 incidents (123:10,000, 95% CI 108.5-139.8). Most frequently, incidents involved patients under 1 year (approximately 120:10,000). Most commonly, incidents occurred among those with a classification of ASAII (38%), among those undergoing elective surgery (71.4%), and during the intraoperative period (65.5%). Incidents related to the airway (27.5%) were the most common; including desaturation (11.0:10,000) and aspiration (6.3:10,000). The second most common type of incident involved the cardiovascular system (24.6%). The rate of cardiac arrest was 25.6:10,000 with a respective mortality of 15:10,000. The factors associated with a lower number of incidents were vigilance (29.5%) and staff experience (22.1%). The corrective strategies suggested were used for quality assurance activities in 35.4% of cases, and practical guidelines were developed in 31.3% of cases.
Conclusion: Most common anesthesia incidents were incidents related to the airway and cardiovascular system. The critical anesthesia incident report is a useful tool for better understanding and prevention of perioperative events accompany with continue quality improvement.
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