Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

Prospective analysis of intraoperative critical incidents relevant to anaesthesia in a tertiary care teaching hospital in India

Background and Aims

Critical incidents associated with anesthesia can affect the patient's outcome, may cause transient damage, and contribute to mortality. We aimed at recording anesthesia-related critical incidents in patients undergoing general surgical, ear, nose, and throat (ENT) and orthopedic surgical procedures in our institution. The critical incidents data were analyzed regarding the cause to establish protocols to prevent recurrences.

Material and Methods

We conducted a prospective analysis of voluntarily reported perioperative critical incidents occurring in patients subjected to anesthesia over 1 year. Critical incidents were noted in terms of time (while inducing/intraoperative/while extubating), location (operating theater/recovery room) of the incident, anesthesia-related or surgery-related complications. Data collected were expressed as numbers and proportions to calculate incidence.

Results

Anesthesia was administered to 5,645 patients of which 131 (2.32%) patients had critical incidents. Of these 131, 46 (35.11%) patients had more than one critical incident. A total of 216 (3.82%) critical incidents were noted. A majority of the patients were in the age range of 51-60 years. The maximum incidents occurred during the intraoperative period (35.11%) and in the operating theater (86.25%). Of the 216 incidents, 154 (71.30%) were anesthesia-related, 18 (8.33%) were surgery-related, 1 (0.46%) was patient-related and 43 (19.91%) were recovery-related. Of the 216 incidents, cardiovascular-related incidents accounted for the maximum incidents (18.05%, n = 39). Most of the events were preventable.

Conclusion

The critical incident reporting system should be encouraged and protocols established to reduce the frequency and severity of these occurrences.

A desktop systems analysis of critical incidents within a university hospital department of anaesthesia

INTRODUCTION

Medical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system.

METHODS

Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly.

RESULTS

Seventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department.

CONCLUSION

Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.

Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students: A case-control study

BACKGROUND

Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences.

OBJECTIVES

The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training.

DESIGN

Observational case-control study.

SETTINGS

Four critical event scenarios were created using full-scale simulation.

PARTICIPANTS

Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course.

METHODS

Stress levels were assessed using the self-report stress numerical rating scale-11.

RESULTS

There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p < 0.05) and expected after the session (p < 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212).

CONCLUSIONS

The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

Composition and risk assessment of perioperative patient safety incidents reported by anesthesiologists from 2009 to 2019: a single-center retrospective cohort study

Background

Patient safety incident (PSI) reporting has been an important means of improving patient safety and enhancing organizational quality control. Reports of anesthesia-related incidents are of great value for analysis to improve perioperative patient safety. However, the utilization of incident data is far from sufficient, especially in developing countries such as China.

Methods

All PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and August 2019 were collected from the incident reporting system. We reviewed the freeform text reports, supplemented with information from the patient medical record system. Composition analysis and risk assessment were performed.

Results

In total, 847 PSIs were voluntarily reported by anesthesiologists during the study period among 452,974 anesthetic procedures, with a reported incidence of 0.17%. Patients with a worse ASA physical status were more likely to be involved in a PSI. The most common type of incident was related to the airway (N = 208, 27%), followed by the heart, brain and vascular system (N = 99, 13%) and pharmacological incidents (N = 79, 10%). Those preventable incidents with extreme or high risk were identified through risk assessment to serve as a reference for the implementation of more standard operating procedures by the department.

Conclusions

This study describes the characteristics of 847 PSIs voluntarily reported by anesthesiologists within eleven years in a Chinese academic hospital. Airway incidents constitute the majority of incidents reported by anesthesiologists. Underreporting is common in China, and the importance of summarizing and utilizing anesthesia incident data should be scrutinized.

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

OBJECTIVE

Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents.

METHODS

One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs.

RESULTS

Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1-5]/10 and 3 [1-5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1-5]/10 (p=0.498).

CONCLUSION

This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health.

Review of critical incidents in a university department of anaesthesia

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

Critical incidents during anesthesia in a developing country: A retrospective audit

Background:

Critical incidents occur inadvertently where ever humans work. Reporting these incidents and near misses is important in learning and prevention of future mishaps. The aim of our study was to identify the incidence, outcome and potential risk factors leading to critical incidents during anaesthesia in a tertiary care teaching hospital and attempt to suggest preventive strategies that will improve patient care.

Materials and Methods:

A retrospective audit of all anaesthesia charts for documented critical incidents over a 12 month period was carried out. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anaesthetists were noted. The data collected was analysed using the SPSS software.

Results:

Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. More females suffered critical incidents. Patients in the 4^th and 5^th decades of life were noted to be more susceptible. Airway and cardiovascular incidents were the commonest. Anaesthetists with less than 6 years experience were involved in more mishaps.

Conclusion:

We conclude that airway mishaps and cardiovascular instability were the commonest incidents especially in the hands of junior anaesthetists.

Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures

BACKGROUND

Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS).

METHODS

Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement.

RESULTS

Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3).

CONCLUSIONS

This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.

Development, implementation and impact of simple patient safety interventions in a university teaching hospital

OBJECTIVE

To determine the incidence of anesthesia patient safety incidents at a university teaching hospital, develop interventions to address the most common incidents, and determine the effectiveness of these interventions.

STUDY DESIGN

Pre-post intervention observational.

ANIMALS

Four thousand, one hundred forty dogs and cats anesthetized by the anesthesia service.

METHODS

The study was divided into two 11.5 month periods. During each period, incidents were logged (e.g. closed adjustable pressure limiting (APL) valve, esophageal intubation, and medication error). At the end of the first period, four countermeasures were incorporated into the service's protocols: 1) prior to any drug injection, the individual would read out aloud the drug name, patient name, and route of administration; 2) use of a uniquely colored occlusive wrap over arterial catheters; 3) a check box on the anesthesia record labeled "Technician Confirmed Intubation"; 4) a check box on the anesthesia record labeled "Technician Checked OR (operating room)". The number of patient safety incidents during period 1 and period 2 were compared using Fisher's Exact Test.

RESULTS

During Period 1, there were 74 incidents documented in 2028 patients (3.6%) including 25 medication errors, 20 closed APL valves, and 16 of esophageal intubation. During Period 2, there were 30 incidents documented in 2112 patients (1.4%) including 14 medication errors, 5 closed APL valves, and 4 of esophageal intubation. The proportion of events during Period 2 was significantly smaller than during Period 1 (p < 0.0001).

CONCLUSIONS AND CLINICAL RELEVANCE

Implementation of four simple interventions was associated with a significant decrease in the number of incidents.

National critical incident reporting systems relevant to anaesthesia: a European survey

BACKGROUND

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia.

METHODS

We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure.

RESULTS

Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed.

CONCLUSIONS

We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

Evolution of anaesthesia care and related events between 1996 and 2010 in Switzerland

BACKGROUND

Anaesthesia Databank Switzerland (ADS) is a voluntary data registry introduced in 1996. Its ultimate goal is to promote quality in anaesthesiology.

METHODS

The ADS registry analyses routinely recorded adverse events and provides benchmark comparisons between anaesthesia departments. Data collection comprises a set of 31 variables organised into three modules, one mandatory and two optional.

RESULTS

In 2010, the database included 2,158,735 anaesthetic procedures. Over time, the proportions of older patients have increased, the largest group being aged 50-64 years. The percentage of patients with American Society of Anesthesiologists (ASA) status 1 has decreased while the percentage of ASA status 2 or 3 patients has increased. The most frequent comorbidities recorded were hypertension (21%), smoking (16%), allergy (15%) and obesity (12%). Between 1996 and 2010, 125,579 adverse events were recorded, of which 34% were cardiovascular, 7% respiratory, 39% technical and 20% non-specific. The most severe events were resuscitation (50%), oliguria (22%), myocardial ischaemia (17%) and haemorrhage (10%).

CONCLUSION

Routine ADS data collection contributes to the monitoring of trends in anaesthesia care in Switzerland. The ADS system has proved to be usable in daily practice, although this remains a constant challenge that is highly dependent on local quality management and quality culture. Nevertheless, success in developing routine regular feedback to users to initiate discussions about anaesthetic events would most likely help strengthen departmental culture regarding safety and quality of care.

[Systematic collection and analysis of intraoperative anaesthetic-related problems]

OBJECTIVE

The purpose of the study was to systematically collect and analyse the frequency, type and severity of all untoward intraoperative anaesthetic-related problems in a hospital over a 6-month period.

METHODS

An observational, systematic, prospective, and cross sectional study was conducted on the events and their risk factors. The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis, including sedation and obstetric analgesia. The variables were demographic, procedural data, and a checklist with problem type and severity. Data were analysed using chi-square, Fisher's test, or Student's test. A P<.05 was considered statistically significant.

RESULTS

The frequency of intraoperative anaesthetic-related problems was 17.2%, with 1.3 anaesthetic problems per case, being 9 times more frequent the adverse effects with low severity grade. During anaesthesia, respiratory problems occurred in 13, circulatory problems in 8, and technical problems in 2 out of every 100 procedures. The factors associated with the patient in whom the anaesthetic problem occurred were: the use of general anaesthesia, supraumbilical surgery, and a higher preoperative anaesthetic risk.

CONCLUSIONS

Use of a systematic intraoperative anaesthetic-related database with a checklist of problems and severity plays an important part in quality assurance strategies. An analysis of non-fatal problems provides a basis for establishing corrective strategies before significant morbidity occurs, and by separating the surgical and anaesthesia problems.

Adverse physiological events under anaesthesia and sedation: a pilot audit of electronic patient records

Review of perioperative activity including adverse events, throughput and compliance with 'best practice', can theoretically be used to optimise healthcare delivery. Computer-based analysis of electronic patient records could provide a practical means to manage quality improvement. This pilot study examined the effectiveness of such a system in practice. All intraoperative patient notes and physiological data were collected over 17 months in a rural hospital using data from an electronic record-keeping system. Algorithms were developed to automatically identify potential adverse events based on physiological measures. Each computer-identified event was reviewed by a panel of three anaesthetists and assessed for validity, severity and probable cause. Two areas were identified to pilot quality improvement activities-sedation for colonoscopies and inhalational anaesthesia with desflurane. Specific 'in-house' guidelines were created for these procedures and feedback on the patterns of adverse events were provided to anaesthetic staff A total of 138 separate adverse events were identified for all operative cases over 17 months, with an overall adverse event incidence of 3.3%. The adverse event incidence during colonoscopy and laryngospasm/hypoxia during desflurane anaesthesia was 6.3% and 1.3% respectively. This decreased to 2.8% (P <0.005) and 0.13% (P <0.0001) respectively for the nine months following feedback and the introduction of guidelines. Anaesthesia information systems can be an effective quality improvement tool and may enhance existing tools such as incident reporting systems.