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2015 ; 62
(12
): 1248-58
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Reporting critical incidents in a tertiary hospital: a historical cohort study of
110,310 procedures
#MMPMID26407581
Munting KE
; van Zaane B
; Schouten AN
; van Wolfswinkel L
; de Graaff JC
Can J Anaesth
2015[Dec]; 62
(12
): 1248-58
PMID26407581
show ga
PURPOSE: Investigation of adverse events associated with anesthetic procedures is
a method of quality control that identifies topics to improve clinical care and
patient safety. Most research to date has been based on closed claim registries
and anonymous reports which have specific limitations. Therefore, to evaluate a
hospital's reporting system, the present study was designed to describe critical
incidents that anesthesiologists voluntarily and non-anonymously reported through
an anesthesia information management system. METHODS: This is a historical
observational cohort study on patients (age > 18 yr) undergoing anesthetic
procedures in a tertiary referral hospital. A 20-item list of complications, as
developed by the Netherlands Society of Anesthesiologists, was prospectively
completed for each procedure. All critical incidents registered in the anesthesia
information management system were then reclassified into 95 different critical
incidents in a reproducible way. RESULTS: There were 110,310 procedures performed
in 65,985 patients, and after excluding 158 reports that did not depict a
critical incident, 3,904 critical incidents in 3,807 (3.5%) anesthetic procedures
remained. Technical difficulties with regional anesthesia (n = 445; 40 per 10,000
anesthetics; 95% confidence interval [CI], 36 to 44), hypotension (n = 432; 39
per 10,000 anesthetics; 95% CI, 35 to 43), and unexpected difficult intubation (n
= 216; 20 per 10,000 anesthetics; 95% CI, 18 to 23) were the most frequently
documented critical incidents. CONCLUSION: Accurate measurement and monitoring of
critical incidents is crucial for patient safety. Despite the risk of
underreporting and probable misclassification of manual reporting systems, our
results give a comprehensive overview on the occurrence of voluntarily reported
anesthesia-related critical incidents. This overview can direct development of a
new reporting system and preventive strategies to decrease the future occurrence
of critical incidents.