Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 119
  • Home
  • Print this page
  • Email this page
ORIGINAL RESEARCH REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 18-24

Critical incidents and near misses during anesthesia: A prospective audit


1 Department of Anaesthesia and Intensive Care, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Anaesthesia and Intensive Care, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria

Correspondence Address:
Pamela Onorame Agbamu
Department of Anaesthesia and Intensive Care, Lagos University Teaching Hospital, PMB 12003, Lagos
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-6859.199170

Rights and Permissions

Background: A critical incident is any preventable mishap associated with the administration of anesthesia and which leads to or could have led to an undesirable patients' outcome. Patients' safety can be improved by learning from reported critical incidents and near misses. Materials and Methods: All perioperative critical incidents (excluding obstetrics) occurring over 5 months were voluntarily documented in a pro forma. Age of patient, urgency of surgery, grade of anesthetist, and patients' outcome was noted. Results: Seventy-three critical incidents were recorded in 42 patients (incidence 6.1% of 1188 procedures) with complete recovery in 88.1% (n = 37) and mortality in 11.9% (n = 5). The highest incidents occurred during elective procedures (71.4%), which were all supervised by consultants, and in patients aged 0–10 years (40.1%). Critical incident categories documented were cardiovascular (41.1%), respiratory (23.25%), vascular access (15.1%), airway/intubation (6.85%), equipment errors (6.85%), difficult/failed regional technique (4.11%), and others (2.74%). The monitors available were: pulse oximetry (100%), precordial stethoscope (90.5%), sphygmomanometer (90.5%), capnography (54.8%), electrocardiogram (31%), and temperature (14.3%). The most probable cause of critical incident was patient factor (38.7%) followed by human error (22.5%). Equipment error, pharmacological factor, and surgical factor accounted for 12.9%. Conclusion: Critical incidents can occur in the hands of the highly skilled and even in the presence of adequate monitoring. Protocols should be put in place to avoid errors. Critical incident reporting must be encouraged to improve patients' safety and reduce morbidity and mortality.


[FULL TEXT] [PDF]*
Print this article     Email this article
 Next article
 Previous article
 Table of Contents

 Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
 Citation Manager
 Access Statistics
 Reader Comments
 Email Alert *
 Add to My List *
 * Requires registration (Free)
 

 Article Access Statistics
    Viewed2059    
    Printed24    
    Emailed0    
    PDF Downloaded268    
    Comments [Add]    

Recommend this journal