IJCM  Vol.7 No.5 , May 2016
Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital
Abstract: Introduction: Critical incident monitoring is important in quality improvement as it identifies potential risks to patients by analyzing adverse events or near-misses. Methods: This study analyses the reported incidents in a tertiary hospital over a 4-year period. Results: A total of 441 incidents were reported out of 98,502 anesthetics performed during the study period. Of these incidents, 67 resulted in no harm caused, 116 with unanticipated ICU admissions and 20 mortalities. The odds of having a critical incident increased with ASA status: from an odds ratio of 2.08 (95% CI: 1.58 to 2.74) for ASA 2 patients compared to ASA1, to OR of 13.70 (5.91 to 31.74) in ASA 5 compared to ASA 1. Critical incidents also have higher odds occurring out of hours (OR 1.7 (1.45 to 2.23) compared to daytime hours (08:00-17:00). They occurred most commonly in maintenance phase (142, 32.7%), followed by induction (120, 27.6%). The most common types of incidents include airway and respiratory (110, 24.9%) followed by drug related incidents (67, 15.2%). Human error was attributed as a significant contributing factor in 276 incidents (61.5%) followed by patient factors in 112 incidents (25.4%). Mitigating factors such as vigilance by staff involved were significant in 136 incidents (30.3%). Conclusion: Higher ASA status appears to be the most important factor associated with actual or potential patient harm in our study. Also significant, was time of incident, with incidents more likely out of hours. Critical incident reporting is a valuable part of quality assurance. We should continue to invest in incident reporting, incident analysis and improvement plans.
Cite this paper: Zeng, L. , Yi Ng, S. and Thong, S. (2016) Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital. International Journal of Clinical Medicine, 7, 320-333. doi: 10.4236/ijcm.2016.75034.

[1]   Flanagan, J.C. (1954) The Critical Incident Technique. Psychological Bulletin, 5, 327-358.

[2]   Cooper, J.B., Newbower, R.S., Long, C.D. and McPeek, B. (1978) Preventable Anesthesia Mishaps: A Study of Human Factors. Anesthesiology, 49, 399-406.

[3]   Runciman, W.B. (1988) The Australian Patient Safety Foundation. Anaesthesia and Intensive Care, 18, 98-100.

[4]   Webb, R.K., Currie, M., Morgan, C.A., Williamson, J.A., Mackay, P., Russell, W.J. and Runciman, W.B. (1993) The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports. Anaesthesia and Intensive Care, 21, 520-528.

[5]   Choy, C.Y. (2008) Critical Incident Monitoring in Anaesthesia. Current Opinion in Anesthesiology, 21, 183-186.

[6]   Rooksby, J., Gerry, B. and Smith, A.F. (2007) Incident Reporting Schemes and the Need for a Good Story. International Journal of Medical Informatics, 76, 205-211.

[7]   National Patient Safety Agency (2005) Seven Steps to Patient Safety: Full Reference Guide. NPSA, London, 100.

[8]   Kumar, V., Barcelos, W.A., Mehta, M.P. and Carter, J.G. (1988) An Analysis of Critical Incidents in a Teaching Department for Quality Assurance. Anaesthesia, 43, 879-883.

[9]   Galletly, D.C. and Mushnet, N.N. (1991) Anaesthesia System Errors. Anaesthesia and Intensive Care, 19, 66-73.

[10]   Khan, F.A. and Hoda, Q.A. (2001) A Prospective Survey of Intra-Operative Critical Incidents in a Teaching Hospital in a Developing Country. Anaesthesia, 56, 171-182.

[11]   Short, T.G., O’Regan, A., Lew, J. and Oh, T.E. (1992) Critical Incident Reporting in an Anesthetic Department Quality Assurance Programme. Anaesthesia, 47, 3-7.

[12]   Gupta, S., Naithani, U., Brajesh, S.K., Pathania, V.S. and Gupta, A. (2009) Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit. Indian Journal of Anaesthesia, 53, 425-433.

[13]   Freestone, L., Bolsin, S.N., Colson, M., Patrick, A. and Creati, B. (2006) Voluntary Incident Reporting by Anaesthetic Trainees in an Australian Hospital. International Journal for Quality in Health Care, 18, 452-457.

[14]   Maaloe, R., la Cour, M., Hansen, A., Hansen, E.G., Hansen, M., Spangsberg, N.L., Landsfeldt, U.S., Odorico, J., Olsen, K.S., Moller, J.T. and Pederson, T.L. (2006) Scrutinizing Incident Reporting in Anaesthesia: Why Is an Incident Perceived as Critical? Acta Anaesthesiologica Scandinavica, 50, 1005-1013.

[15]   Runciman, W.B. (2002) Lessons from the Australian Patient Safety Foundation: Setting up a National Patient Safety Surveillance System—Is This the Right Model? Quality & Safety in Health Care, 11, 246-251.

[16]   Haller, G., Courvoisier, D.S., Anderson, H. and Myles, P.S. (2011) Clinical Factors Associated with the Non-Utilization of an Anaesthesia Incident Reporting System. British Journal of Anaesthesia, 107, 171-179.

[17]   Braz, L.G., Modolo, N.S.P., Mascimento, P., do Nascimento Jr., P., Bruschi, B.A., Castiglia, Y.M., Ganem, E.M., de Carvalho, L.R. and Braz, J.R. (2006) Perioperative Cardiac Arrest: A Study of 53,718 Anesthetics over 9 Years from a Brazilian Teaching Hospital. British Journal of Anaesthesia, 95, 569-575.

[18]   Manghanani, P.K., Shinde, V.S. and Chaudhari, L.S. (2004) Critical Incidents during Anaesthesia “An Audit”. Indian Journal of Anaesthesia, 48, 287-294.

[19]   Currie, M. (1989) A Prospective Survey of Anaesthetic Critical Events in a Teaching Hospital. Anaesthesia and Intensive Care, 17, 403-411.

[20]   Arbous, M.S., Grobboe, D.E., van Kleef, J.W., de Lange, J.J., Spooormans, H.H., Touw, P., Werner, F.M. and Meursing, A.E. (2001) Mortality Associated with Anaesthesia: A Qualitative Analysis to Identify Risk Factors. Anaesthesia, 5, 1141-1153.

[21]   Turkistani, A., El-Dawlatly, A.A., Delvi, B., Alotaibi, W. and Abdulghani, B. (2009) Critical Incident Monitoring in a Teaching Hospital. Middle East Journal of Anesthesiology, 20, 97-100.

[22]   Charuluxananan, S., Punjasawadwong, Y., Suraseranivongse, S., Srisawasdi, S., Kyokong, O., Chinachoti, T., Chanchayanon, T., Rungreungvanich, M., Thienthong, S., Sirinan, C. and Rodanant, O. (2005) The Thai Anesthesia Incidents Study (THAI Study) of Anesthetic Outcomes: II. Anesthetic Profiles and Adverse Events. Journal of the Medical Association of Thailand, 88, S14-S29.

[23]   Cross, P., Cytryn, J. and Cheng, K.K. (2007) Perforation of the Soft Palate Using the GlideScope Videolaryngoscope. Canadian Journal of Anesthesia, 54, 588-589.

[24]   Vincent Jr., R.D., Wimberly, M.P., Brockwell, R.C. and Magnuson, J.S. (2007) Soft Palate Perforation during Orotracheal Intubation Facilitated by the GlideScope Videolaryngoscope. Journal of Clinical Anesthesia, 19, 619-621.

[25]   Leong, W.L., Lim, Y. and Sia, A.T. (2008) Palatopharyngeal Wall Perforation during GlideScope Intubation. Anaesthesia and Intensive Care, 36, 870-874.

[26]   Cooper, R.M. (2007) Complications Associated with the Use of the GlideScope Videolaryngoscope. Canadian Journal of Anesthesia, 54, 54-57.

[27]   Amundson, A.W. and Weingarten, T.N. (2013) Traumatic GlideScope(®) Videolaryngoscopy Resulting in Perforation of the Soft Palate. Canadian Journal of Anesthesia, 60, 210-211.

[28]   Olsson, G.L., Hallen, B. and Hambracus-Jonzon, K. (1986) Aspiration during Anesthetics. Acta Anaesthesiologica Scandinavica, 30, 84-92.

[29]   Mellin-Olsen, J., Fastin, S. and Gisvold, S.E. (1996) Routine Preoperative Gastric Emptying Is Seldom Indicated: A Study of 85,594 Anesthetics with Special Focus on Aspiration Pneumonia. Acta Anaesthesiologica Scandinavica, 40, 1184-1188.

[30]   Warner, M.A., Warner, M.E. and Weber, J.G. (1993) Clinical Significance of Pulmonary Aspiration during the Preoperative Period. Anesthesiology, 78, 56-82.

[31]   Suraseranivongse, S., Valairucha, S., Chanchayanon, T., Mankong, N., Veerawatakanon, T. and Rungreungvanich, M. (2005) The Thai Anesthesia Incidents Study (THAI Study) of Pulmonary Aspiration: A Qualitative Analysis. Journal of the Medical Association of Thailand, 88, S76-S83.

[32]   Kluger, M.T. and Short, T.G. (1999) Aspiration during Anesthesia: A Review of 133 Cases from the Australian Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia, 54, 19-26.

[33]   Ng, A. and Smith, G. (2001) Gastroesophageal Reflux and Aspiration of Gastric Contents in Anesthetic Practice. Anesthesia & Analgesia, 93, 494-513.

[34]   Pereira, L.A. and Fisher, D.A. (2008) Methicillin-Resistant Staphylococcus aureus Control in Singapore—Moving Forward. Annals of the Academy of Medicine, Singapore, 37, 891-896.

[35]   Sorrell, T.C. and Collignon, P.J. (1985) A Prospective Study of Adverse Reactions Associated with Vancomycin Therapy. Journal of Antimicrobial Chemotherapy, 16, 235-241.

[36]   Mellor, J.A., Kingdom, J., Cafferkey, M. and Keane, C.T. (1985) Vancomycin Toxicity: A Prospective Study. Journal of Antimicrobial Chemotherapy, 15, 773-780.

[37]   Savarese, A., Nanni, M.L., Pasquali, C. and Egidio, A.C. (1999) Vancomycin Prophylaxis in Joint Arthroplasty. La Chirurgia degli Organi di Movimento, 84, 247-251.

[38]   Wazny, L.D. and Daghigh, B. (2001) Desensitization Protocols for Vancomycin Hypersensitivity. Annals of Pharmacotherapy, 35, 1458-1464.

[39]   Alexander, J.W., Solomkin, J.S. and Edwards, M.J. (2011) Updated Recommendations for Control of Surgical Site Infections. Annals of Surgery, 253, 1082-1093.

[40]   Hafermann, M.J., Kiser, T.H., Lyda, C., Fish, D.N., Barber, G.R., Wempe, M.F. and Cleveland Jr., J.C. (2014) Weight-Based versus Set Dosing of Vancomycin for Coronary Artery Bypass Grafting or Aortic Valve Surgery. The Journal of Thoracic and Cardiovascular Surgery, 147, 1925-1930.

[41]   Toff, N.J. (2010) Human Factors in Anaesthesia: Lessons from Aviation. British Journal of Anaesthesia, 105, 21-25.

[42]   Bion, J.F., Abrusci, T. and Hibbert, P. (2010) Human Factors in the Management of Critically Ill Patient. British Journal of Anaesthesia, 105, 26-33.

[43]   van Beuzekom, M., Boer, F., Akerboom, S. and Hudson, P. (2010) Patient Safety: Latent Risk Factors. British Journal of Anaesthesia, 105, 52-59.

[44]   Mahajan, R.P. (2011) Medication Errors: Can We Prevent Them? British Journal of Anaesthesia, 107, 3-5.

[45]   Tiret, L., Desmonts, J.M., Hatton, F. and Vourc’h, G. (1986) Complications Associated with Anesthesia—A Prospective Survey in France. Canadian Anaesthetists’ Society Journal, 33, 336-344.

[46]   Newland, M.C., Ellis, S.J., Lydiatt, C.A., Peters, K.R., Peters, K.R., Tinker, J.H., Romberg, D.J., Ullrich, F.A. and Anderson, J.R. (2002) Anesthetic-Related Cardiac Arrest and Its Mortality: A Report Covering 72,959 Anesthetics over 10 Years from a US Teaching Hospital. Anesthesiology, 97, 108-115.

[47]   Lienhart, A., Auroy, Y., Péquignot, F., Benhamou, D., Warsgawski, J., Bovet, M. and Jougla, E. (2006) Survey of Anesthesia-Related Mortality in France. Anesthesiology, 105, 1087-1097.

[48]   Mahajan, R.P. (2010) Critical Incident Reporting and Learning. British Journal of Anaesthesia, 105, 69-75.

[49]   Smith, A.F., Goodwin, D., Mort, M. and Pope, C. (2006) Adverse Events in Anaesthetic Practice: Qualitative Study of Definition, Discussion and Reporting. British Journal of Anaesthesia, 96, 715-721.