Incidence and Classification of Nonroutine Events during Anesthesia Care (original) (raw)

Risk of unanticipated intraoperative events in patients assessed at a preanaesthetic clinic

Canadian Journal of Anaesthesia, 1997

Pro-pose: To determine the risk of unanticipated intraoperative events (UIE) in patients assessed at a preanaesthetic clinic compared with those not assessed at the clinic. Mt~hods: Preoperative and intraoperative data were collected on 6130 elective surgical patients by procedural anaesthetists over a 12-month period at an Australian tertiary referral hospital. The procedural anaesthetists rated the level of preparation and identifmcl predefined unanticipated intraoperative events. A logistic regression model was used to identify significant risk factors of UIE and was further validated on another sample of 482 patients (one month) by a goodness-of-re test. l~ttlts: Of the 6130 elective surgical patients, 2000 (33%) had been assessed at the preanaesthetic clinic. There was a greater proportion of ASA II to IV patients seen at the clinic than patients not assessed at the clinic (X2]=689.92, P < 0.001). Nonclinic patients were more likely to be inadequately prepared than clinic patients (RR ~ae~= 1.61,95%0:1.25 to 2.04, P < 0.001). The overall incidence of intraoperative events was 4. 14% (95%CI: 3.64% to 4.64%). Despite adjusting for the preparation level, type of anaesthesia, admission category, ASA physical status and duration of anaesthesia, clinic patients were 1.94 (95%CI: 1.42 to 2.64) times more likely to experience an UIE than nonclinic patients (P < 0.001). Conclusion: Although clinic patients were more often optimally prepared, their adjusted risk of UIE was higher than nonclinic patients. The procedural anaesthetist needs to be vigilant with these high risk patients, even if they have been assessed at a preanaesthetic clinic.

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting

British Journal of Anaesthesia, 2006

Background. This study aimed to explore how critical and acceptable practice are defined in anaesthesia and how this influences the discussion and reporting of adverse incidents. Method. We conducted workplace observations of, and interviews with, anaesthetists and anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively for adverse events in anaesthetic process witnessed. We also observed departmental audit meetings and analysed meeting minutes and report forms. Results. The educational value of discussing events was well-recognized; 28 events were discussed at departmental meetings, of which 5 (18%) were presented as 'critical incidents'. However, only one incident was reported formally. Our observations of anaesthetic practice revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were acknowledged as offering the potential to improve safety, although some were direct violations of 'acceptable' practice. Formal reporting appears to be constrained by changing boundaries of what might be considered 'critical', by concerns of loss of control over formally reported incidents and by the perception that reporting schemes outside anaesthesia have purposes other than education. Conclusions. Despite clear official definitions of criticality in anaesthesia, there is ambiguity in how these are applied in practice. Many educationally useful events fall outside critical incident reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but the reluctance to adopt a more explicit 'systems approach' to adverse events may impede further gains in patient safety in anaesthesia.

Adverse events in anaesthesia care

Kontakt

The goal of this review study was to summarize research conclusions on reported adverse events in anaesthesia care regarding paediatric and adult patients in the last 10 years. Methods: Relevant sources were found in scientific databases EBSCO, PubMed, Science Direct, Wiley and Scopus. We used the following keywords: adverse events/incident/malpractice, anaesthesia, report. Other criteria for the inclusion of studies were: full-text, English language, publications that were no older than 10 years (2009-2019) and human related. In the end, we included 15 studies. Results: The studies (analytical, prospective, retrospective, cohort, observational, systematic revisions and meta-analyses) mostly specify the areas and frequencies of reported adverse events and deal with the efficiency of report procedures and their implementation in clinical practice. The most frequent adverse events that occurred in anaesthesia care were respiration and cardiovascular problems and medical errors. The level of their occurrence varied by the patients' age. Conclusions: The monitoring and assessment of adverse events is an effective instrument for the improvement of quality and safety in anaesthesia practical care. The main problem is the unwillingness of medical workers to participate in reporting adverse events and the incompatibility of adverse event databases in anaesthesia care.

Practical considerations in the development of a nonoperating room anesthesia practice

Current opinion in anaesthesiology, 2016

More than 25% of the procedures necessitating an anesthesia provider's involvement are performed outside the operating room. As a result, it is imperative that the expansion of anesthesia services to any new nonoperating room anesthesia (NORA) location takes into account the challenges and safety considerations associated with such a transformation. Although the adverse events encountered in the NORA suite are similar to those met in the operating room, the frequency and implications are different. In addition, many adverse events are site specific. Hypoxemia events, including cardiac arrest continue to dominate all areas of NORA practice. Challenges posed by new minimally invasive procedures continue to grow. Electronic documentation is rapidly expanding into the NORA suite, which brings both advantages and challenges. Involvement of anesthesia providers at the development stage and an understanding of the administrative and clinical challenges are essential elements in the bui...

A prospective survey of anaesthetic critical events in a teaching hospital

Anaesthesia and intensive care, 1989

A survey of anaesthetic critical events based on voluntary anonymous reports was undertaken over a two and a half year period within a teaching hospital Department of Anaesthesia. At the end of the survey 167 reports were analysed. Human error was a contributing factor in 82% of events. Inadequate preoperative patient assessment or preparation, problems in the area of human/equipment interface and various stress factors for the anaesthetist featured significantly in the survey. The method enables the collection of objective data on factors contributing to anaesthetic and surgical risk and the formulation and evaluation of potential corrective strategies. It also facilitates harmonious peer review via individual and group feedback activities. The adoption of such a survey on a wider scale is seen as a valuable part of quality assurance in the continuing attempt to increase patient safety.

Critical incidents in anaesthesia: medicolegal and other aspects

Canadian Journal of Anaesthesia, 1991

The title of the Tenth Annual Anaesthetic Symposium of the Department of Anaesthesia, Foothills Hospital at the University of Calgary was "Critical incidents in anaesthesia: medico-legal and other aspects." The purpose of the symposium was to review the latest in the field of human factors implicated in the genesis of critical incidents. Similarities to accidents in aviation were identified and the medico-legal consequences were explored. Dr. Rob Lee began by describing the success of the aviation industry in developing a high standard of safety. He emphasized the importance of investigation of accidents, the development of a computerized database , and the relevance of the study of human factors in both aviation and anaesthesia. Dr. Jeffery Cooper followed with a description of methods of measuring untoward outcome in anaesthesia. He indicated the need to examine various types of adverse events but indicated that the subject studied would depend on the particular anaesthetic "culture." Dr. Jan Davies reviewed the theory of riskmanagement policies as applied to unanticipated adverse events, comparing American and Canadian aspects. She then described the particular system used at Foothills Hospital and emphasized the importance of a process for "emotional debriefing." Dr. J. N. Armstrong outlined the system for investigation of anaesthetic accidents which he and Doctors Davies and Lee have developed. He drew the analogy between the study of accidents in aviation and anaesthesia and indicated the trend to examine factors

The Thai anesthesia incidents study (THAI study) of anesthetic adverse outcomes

European Journal of Anaesthesiology, 2006

Background and rationale : The purposes of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes were to survey patients, surgical, anesthetic profiles and determine factors related to adverse events. Material and Method : A prospective descriptive study of occurrence screening was conducted in 20 hospitals comprised of 7 university, 4 general and 4 district hospitals across Thailand. Anesthesia personnel were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a structured data entry form. The data were collected during the preanesthetic evaluation, intraoperative period and 24 hr postoperative period. Adverse events specific forms were used to record when they occurred. All data were keyed at data management unit with double entry technique and descriptive statistics was used in the first phase of this study. Results : A total of 163403 consecutive cases were recorded during first 12 months. MD. anesthesiologists involved with 82%, 89%, 45% and 0.2% of cases in university hospitals, regional hospitals, general hospitals and district hospitals respectively. Nurse anesthetists took a major involvement in hospitals run by the Ministry of Public Health. Two-thirds of cases did not receive any premedication (67%) and midazolam was most fre- quent premedication administered (20%). Common monitoring were non invasive blood pressure (NIBP) (97%), pulse oximetry (96%), electrocardiography (80%), urine output (33%), airway pressure (27%) and capnometry (19%) respectively. The choices of anesthesia were general anesthesia (62%), spinal anesthesia (23%), total intravenous anesthesia (6%), monitor anesthesia care (4%), brachial plexus block (3%) and epidural anesthe- sia (1%). The adverse events were oxygen desaturation (31.9:10000), cardiac arrest (30.8:10000), death within 24 hr. (28.3:10000), difficult intubation (22.5:10000),re-intubation (19.4:10000), unplanned ICU admission (7.2:10000), coma/cva/convulsion (4.8:10000), equipment malfunction/failure (3.4:10000), suspected myocar- dial ischemia or infarction (2.7:10000), awareness during anesthesia (3.8:10000), late detected esophageal intubation (4.1:10000), failed intubation (3.1:10000), anaphylaxis or anaphylactoid reaction (2.1:10000), nerve injury (2:10000), pulmonary aspiration (2.7:10000), drug error (1.3:10000), hazard to anesthesia personnel (1.5:10000), unplanned hospital admission (0.1:10000), total spinal block (1.3:10000) and mismatch blood transfusion (0.18:10000) Conclusion : Respiratory adverse events were common anesthesia direct related events. High incidence of cardiac arrest and death within 24 hr. highlighted concerns for prevention strategies. Incidents of adverse events can be used for institutional quality improvement, educational quality assurance and further research for patient safety in anesthesia.