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.
Hinweise
This article is accompanied by an editorial. Please see Can J Anesth 2015; 62: this issue.
Author contributions
Karin E. Munting,Bas van Zaane,Antonius N. J. Schouten, and Jurgen C. de Graaff made a substantial contribution to the conception of the study. Karin E. Munting,Bas van Zaane, and Jurgen C. de Graaff made a substantial contribution to the design of the study and performed the data analysis. Karin E. Munting and Leo van Wolfswinkel made a substantial contribution to the acquisition of data. Karin E. Munting,Bas van Zaane, and Leo van Wolfswinkel made a substantial contribution to the interpretation of the data. Karin E. Munting drafted the article and Bas van Zaane was also involved in drafting the article. Karin E. Munting performed the statistical analysis. Bas van Zaane,Antonius N. J. Schouten,Leo van Wolfswinkel, and Jurgen C. de Graaff revised the article critically for important intellectual content.
Monitoring and reporting critical incidents, such as hypotension or a state of awareness, can indicate the quality of clinical practice. Therefore, reporting medical complications voluntarily is encouraged by the World Health Organization and the Dutch Health Care Inspectorate.1,2 Registration of critical incidents not only provides an assessment of the quality of practice but also offers knowledge of the most frequent and most severe critical incidents.
Anesthesiologists should share their experiences with critical incidents in order to increase their knowledge of the potential risks and identify patterns in the development of critical incidents. The gaps and inadequacies found in the healthcare system can be optimized to improve patient safety.3-9 Furthermore, evaluation and feedback constantly encourage clinicians to report critical incidents.3,10
Anzeige
Many countries have developed systems to investigate the number and severity of these critical incidents.7,11-20 Most research has been based on closed claim analysis or anonymous reporting systems; however, these methods have limitations. For example, closed claim analyses will not contain all complications, only those that involve patients and are deemed important. Therefore, in order to evaluate a hospital reporting system and identify topics to improve clinical care and patient safety, we designed the present study to describe critical incidents that anesthesiologists reported voluntarily and non-anonymously through an anesthesia information management system (AIMS) in a tertiary referral hospital.
Methods
Study design
The Institutional Review Board (IRB) of the University Medical Center Utrecht reviewed the study protocol and found that it was not subject to the Dutch Medical Research in Human Subjects Act. Therefore, the IRB waived the need for informed consent (11-271/C; July 5, 2011). This observational study describes prospectively reported critical incidents and complications relating to anesthesia in patients 18 years and older undergoing any type of anesthetic procedure in a tertiary referral university hospital (University Medical Center Utrecht, the Netherlands) from January 1, 2005 to May 18, 2011. Anesthesiologists and anesthesia registrars voluntarily reported complications and critical incidents on a non-anonymous basis via the 20-item complication list of the Netherlands Society of Anesthesiologists. The reporting system was implemented in September 2004; therefore, we chose to evaluate critical incidents reported as of January 1, 2005 to allow an optimization period of three months.
Definitions
We defined a critical incident as an event that could have led (if not discovered or corrected in time) or did lead to an undesirable outcome, i.e., ranging from increased length of hospital stay to death or permanent disability. We included all anesthesia-related critical incidents that occurred at a time when the patient was under the care of an anesthesiologist and were described in clear detail by a person who either observed or was involved in the critical incident. We included critical incidents that not only seemed preventable (i.e., inadequate preoperative screening) or involved human error (i.e., medication error)21 but also were non-preventable (i.e., unexpected difficult intubation).3,15,22
Data acquisition
Critical incidents were reported by anesthesiologists and anesthesia registrars (reporters) in the AIMS on a voluntary and non-anonymous basis. During every anesthetic procedure, a menu item in the AIMS termed complication is presented by pressing the standard event key 〈start skin closure〉, at which time, a reporter can complete a standardized computerized audit form. If a critical incident is reported, a drop down menu displays the 20-item complication list (with miscellaneous as an additional option) developed by the Netherlands Society of Anesthesiologists (Table 1). Thereafter, the incident’s grade of severity can be reported and, if deemed necessary, free text can be added. If the complication report is not entered into the database by the end of the day, the anesthesiologist involved receives a reminder e-mail. Upon completion, the critical incident report is stored in a database within the AIMS along with the patient characteristics. The registry also includes a means to assign a pop-up warning for subsequent anesthetic procedures (i.e., difficult intubation).
Table 1
Classification of critical incidents according to Netherlands Society of Anesthesiologists
Complication
No. incidents (% of total number of incidents, n = 4,062)
Aspiration
54 (1.3%)
Laryngospasm
374 (9.2%)
Hypoxemia
226 (5.6%)
Hypoventilation
195 (4.8%)
Hypertension
76 (1.9%)
Hypotension
700 (17.2%)
Myocardial ischemia / infarction
114 (2.8%)
Cardiac arrhythmia
302 (7.4%)
Acute cardiac decompensation
26 (0.6%)
Dental lesion
36 (0.9%)
Nerve / skin / cornea lesion
141 (3.5%)
Lesion through needle puncture
127 (3.1%)
Hypothermia
79 (1.9%)
Conversion of regional anesthesia / inadequate block
416 (10.2%)
Urinary retention
19 (0.5%)
Inadequate postoperative analgesia
12 (0.3%)
Postoperative agitation
18 (1.7%)
Awareness
51 (1.3%)
Allergic reaction
111 (2.7%)
Transfusion / mediation error
106 (2.6%)
Miscellaneous
879 (21.6%)
Anzeige
The currently used 20-item complication list of the Netherlands Society of Anesthesiologists facilitates a generalized classification of critical incidents. After reviewing the critical incident reports, we concluded that we could not base firm conclusions on the classification system as it was too generalized; therefore, we reclassified all critical incidents. Based on the initial classification and comments added by the reporter, we reclassified the critical incidents in keeping with a classification system of the German Society of Anaesthesiology and Intensive Care13 which is a more detailed classification system on which to base our conclusions. If no comment was available or the comment was unclear, we consulted the AIMS to investigate the critical incident in detail. One researcher (K.M.) reviewed all critical incidents. When information was inconsistent, consensus was reached by discussion with two researchers (J.d.G. and B.v.Z.). If more than one category was possible for one critical incident, the most appropriate or most severe category was chosen. If different critical incidents occurred during one anesthetic procedure, these were categorized as separate critical incidents. All reports involving death as grade of severity were discussed with all observers (K.M., J.d.G., and B.v.Z.).
Statistical analysis
All statistical analyses were performed using SPSS® 17.0 for Windows (SPSS Inc., Chicago, IL, USA), except for the calculation of the 95% confidence interval (CI) according to Wilson’s formula (EpiTools: http://epitools.ausvet.com.au). Procedures with more than one critical incident were counted once. Where appropriate, a Chi square test or an independent samples Student’s t test was carried out to display differences between groups. All reported P values are two sided.
Results
The complication status of 104,133 (94.4%) of 110,310 anesthetic procedures was known (95% CI, 94.2 to 94.5) (Figure). In total, 4,062 events were reported in the AIMS, and 158 (3.9%) reports were classified as not being a critical incident (95% CI, 3.3 to 4.5) because they consisted of surgical complications and warnings for a subsequent anesthetic procedure. The remaining 3,904 critical incidents were found in 3,807 of the 110,310 anesthetic procedures (354 per 10,000 anesthetics; 95% CI, 343 to 365). The 3,904 critical incidents consisted of one single critical incident in 3,715 (97.6%) anesthetic procedures, two critical incidents in 87 (2.3%) anesthetic procedures, and three critical incidents in five (0.1%) anesthetic procedures. Table 2 shows demographic data of the study population; no clinically significant differences were found. The largest critical incident categories were cardiovascular incidents, with 1,164 incidents (106 per 10,000 anesthetics), respiratory problems with 851 incidents (77 per 10,000 anesthetics), and lesions with 820 incidents (74 per 10,000 anesthetics) (Table 3). The cardiovascular critical incidents consisted mainly of hypotension; the respiratory problems critical incidents consisted mainly of difficulties to ventilate (with or without hypoxemia), difficulties to intubate, bronchospasm, and laryngospasm; and the lesion critical incidents consisted mainly of technical difficulties with regional anesthesia (Table 4). The largest groups of reported critical incidents were technical difficulties with regional anesthesia (40 per 10,000 anesthetics) and hypotension (39 per 10,000 anesthetics) (Table 5).
Figure
Flow diagram for reclassification of critical incidents
Table 2
Characteristics of study population
Total number of anesthetics
Anesthetics with critical incidents
Critical incidents per 10,000 anesthetics (95% CI)
P value
110,310
3,807
Mean age
52 (95% CI, 33 to 69)
55 (95% CI, 38 to 72)
<0.001
Sex
0.001
Male
53,741 (48.7%)
1,903 (50.0%)
Female
56,569 (51.3%)
1,904 (50.0%)
ASA classification
<0.001
I
22,148
687
310 (288 to 334)
II
31,948
1,387
434 (412 to 457)
III
7,274
434
597 (545 to 654)
IV
253
18
711 (454 to 1,096)
V
1
0
0 (0 to 7,935)
Not specified
48,686
1,281
263 (249 to 278)
Urgent surgery
<0.001
Elective
89,923
3,138
349 (337 to 361)
Emergency
21,210
669
315 (292 to 339)
ASA = American Society of Anesthesiologists; CI = confidence interval
Table 3
Incidence of critical incidents in the different categories with reported consequence
Consequence of critical incident
Critical incident category
No consequence
Temporary consequence without intervention
Recovery after intervention
(Probable) permanent damage
Death
Death from another cause
None specified
Total (per 10,000 anesthetics; 99% CI)
Largest individual contribution of an anesthesiologist (%)
Respiratory
438
281
15
4
2
0
111
851 (77; 71 to 84)
49 (5.8)
Cardiovascular
397
376
40
41
40
0
270
1,164 (106; 98 to 114)
99 (8.5)
Laboratory results
6
2
0
0
0
0
3
11 (1; 0 to 2)
4 (36.4)
Central Nervous system
45
41
0
0
0
0
26
112 (10; 8 to 13)
11 (9.8)
Equipment / Organization
141
80
3
1
0
2
102
329 (30; 26 to 34)
30 (9.1)
Detriment/injury
443
221
11
7
0
0
138
820 (74; 68 to 81)
36 (4.3)
Medication
167
95
2
1
0
0
58
323 (29; 25 to 34)
18 (5.6)
Miscellaneous
113
135
1
1
1
0
43
294 (27; 23 to 31)
44 (15.0)
Total (per 10,000 anesthetics; 99% CI)
1,750 (159; 149 to 169)
1,231 (112; 104 to 120)
72 (7; 5 to 9)
55 (5; 4 to 7)
43 (4; 3 to 6)
2 (0.2; 0 to 0.9)
751 (68; 62 to 75)
3,904 (354; 340 to 369)
288 (7.4)
Largest individual contribution of an anesthesiologist (%)
88 (5.0)
143 (11.6)
8 (11.3)
7 (13.7)
4 (9.3)
1 (50.0)
111 (14.7)
288 (7.4)
-
The results are limited to those critical incidents for which no greater than 15.0% of the reported incidents were attributed to one anesthesiologist
CI = confidence interval
Table 4
Incidence of the various critical incidents after reclassification
Critical incident
No consequence
Temporary consequence without intervention
Recovery after intervention
(Probable) permanent damage
Death
Death from another cause
None specified
Total (per 10,000 anesthetics)
Respiratory
438
281
15
4
2
0
111
851 (77)
Disconnection
7
0
0
0
0
0
0
7 (1)
Kinking of tube
3
2
0
0
0
0
1
6 (1)
Accidental extubation
18
5
0
0
0
0
2
25 (2)
Unexpected difficult intubation
133
38
1
0
0
0
44
216 (20)
Impossible intubation
13
7
4
0
1
0
3
28 (3)
Failed intubation
12
6
1
0
0
0
2
21 (2)
Mainstem intubation
2
3
0
0
0
0
1
6 (1)
Re-intubation
2
6
2
0
0
0
3
13 (1)
Laryngospasm
49
43
1
0
0
0
6
99 (9)
Bronchospasm
31
41
0
0
0
0
10
82 (7)
Aspiration
7
16
0
1
1
0
8
33 (3)
Hypoventilation / hypoxemia
58
65
1
1
0
0
12
137 (12)
Difficult ventilation*
27
24
1
1
0
0
7
60 (5)
Pulmonary edema
0
1
1
0
0
0
1
3 (0)
Vomiting with laryngeal mask airway*
5
6
0
0
0
0
1
12 (1)
Failure of laryngeal mask airway*
56
11
0
0
0
0
6
73 (7)
Other respiratory disturbances
16
8
3
1
0
0
4
32 (3)
Cardiovascular
397
376
40
41
40
0
270
1,164 (106)
Hypotension
168
121
9
3
0
0
131
432 (39)
Hypertension
18
12
2
1
0
0
15
48 (4)
Arrhythmia
52
51
2
0
3
0
35
143 (13)
Tachycardia
3
6
0
0
0
0
0
9 (1)
Bradycardia
25
11
0
0
0
0
1
37 (3)
Hypovolemia
24
68
17
12
17
0
25
163 (15)
Heart failure
2
13
2
4
4
0
2
27 (2)
Pulmonary embolism
0
0
0
1
1
0
0
2 (0.2)
Circulatory arrest
40
36
2
12
5
0
14
109 (10)
Myocardial infarction
1
6
3
5
5
0
13
33 (3)
Temporary ST-segmental changes*
27
41
3
1
0
0
25
97 (9)
Hemodynamic instability due to sepsis*
3
3
0
2
4
0
5
17 (2)
Vagal response to needle puncture*
33
8
0
0
0
0
4
45 (4)
Other cardiovascular disturbances
0
0
0
0
1
0
0
1 (0.1)
Laboratory results
6
2
0
0
0
0
3
11 (0.3)
Anemia
1
0
0
0
0
0
0
1 (0.1)
Disturbances of electrolytes
3
0
0
0
0
0
2
5 (0.5)
Disturbances of serum glucose
1
2
0
0
0
0
0
3 (0.3)
Other disturbances in laboratory results
1
0
0
0
0
0
1
2 (0.2)
Central nervous system
45
41
0
0
0
0
26
112 (10)
Central anticholinergic syndrome
0
1
0
0
0
0
0
1 (0.1)
Cerebral ischemia
1
0
0
0
0
0
1
2 (0.2)
Seizure
6
8
0
0
0
0
5
19 (2)
Awareness*
2
2
0
0
0
0
3
7 (1)
Postoperative agitation*
9
9
0
0
0
0
3
21 (2)
Reaction of patient during anesthesia without awareness*
24
20
0
0
0
0
13
57 (5)
Transurethral resection (TUR) syndrome*
2
1
0
0
0
0
1
4 (0.4)
Other neurological disturbances
1
0
0
0
0
0
0
1 (0.1)
Equipment / organization
141
80
3
1
0
2
102
329 (30)
Anesthetic machine
18
6
0
0
0
0
2
26 (2)
ECG-monitor
1
0
0
0
0
0
0
1 (0.1)
Monitor of blood pressure
4
2
0
1
0
1
9
17 (2)
External pacemaker
1
0
0
0
0
0
0
1 (0.1)
Pulse oximeter
0
0
0
0
0
0
1
1 (0.1)
Intubation set
2
1
0
0
0
0
1
4 (0.4)
Drug application
2
3
0
0
0
0
2
7 (1)
Insufficient documentation*
14
4
0
0
0
0
16
34 (3)
Inadequate preoperative screening*
15
5
0
0
0
0
15
35 (3)
Inadequate preoperative preparation*
25
22
0
0
0
0
19
66 (6)
Organizational problem*
38
30
3
0
0
1
29
101 (9)
Failure of electronic anesthesia information management system*
8
2
0
0
0
0
1
11 (1)
Electricity failure*
3
2
0
0
0
0
1
6 (1)
Other kind of equipment
10
3
0
0
0
0
6
19 (2)
Detriment / injury
443
221
11
7
0
0
138
820 (74)
Technical difficulties with regional anesthesia
295
73
2
0
0
0
75
445 (40)
Total spinal*
31
10
0
0
0
0
2
43 (4)
Spinal tap*
19
24
0
0
0
0
4
47 (4)
Failed or repeated puncture (blood vessels)
15
7
0
0
0
0
8
30 (3)
Accidental puncture of artery*
24
13
2
0
0
0
7
46 (4)
Teeth
4
7
5
6
0
0
5
27 (2)
Vessels
4
3
0
0
0
0
2
9 (1)
Muscles / soft tissue
3
3
0
0
0
0
4
10 (1)
Skin / lip
17
25
0
0
0
0
5
47(4)
Airway
2
3
0
0
0
0
1
6 (1)
Eyes
0
3
0
1
0
0
2
6 (1)
Epistaxis
15
15
0
0
0
0
3
33 (3)
Pneumothorax / hemothorax
0
5
1
0
0
0
1
7 (1)
Nerves
0
8
0
0
0
0
4
12 (1)
Failed urinary catheter*
6
11
0
0
0
0
8
25 (2)
Accidental removal of intravenous catheter*
7
8
0
0
0
0
4
19 (2)
Other detriment / injury
1
2
1
0
0
0
3
7 (1)
Medication
167
95
2
1
0
0
58
323 (29)
Inappropriate drug*
18
4
0
0
0
0
5
27 (2)
Overdosage*
32
15
0
0
0
0
4
51 (5)
Side effect*
4
5
0
0
0
0
6
15 (1)
Wrong drug*
21
6
0
0
0
0
4
31 (3)
Intravenous injection given subcutaneously*
34
37
1
1
0
0
14
87 (8)
Inadequate administration of medication*
30
12
1
0
0
0
18
61 (6)
Residual muscle paralysis after extubation*
19
11
0
0
0
0
3
33 (3)
Accidental intravenous administration of local anesthetic*
4
1
0
0
0
0
0
5 (0.5)
Other*
5
4
0
0
0
0
4
13 (1)
Miscellaneous
113
135
1
1
1
0
43
294 (27)
Nausea / vomiting
11
6
0
0
0
0
8
25 (2)
Anaphylactic shock
2
21
0
0
1
0
3
27 (2)
Allergic reaction*
45
38
1
0
0
0
11
95 (9)
Shivering
1
0
0
0
0
0
0
1 (0.1)
Hypothermia
28
47
0
0
0
0
4
79 (7)
Transfusion reaction
1
4
0
0
0
0
2
7 (1)
Oliguria / acute renal failure
1
0
0
0
0
0
1
2 (0.2)
Urinary retention*
4
6
0
0
0
0
6
16 (1)
Insufficient postoperative pain management*
2
5
0
0
0
0
2
9 (1)
Positioning*
11
4
0
0
0
0
0
15 (1)
Failed gavage*
1
1
0
0
0
0
0
2 (0.2)
Other
6
3
0
1
0
0
6
16 (1)
Total
1,750
1,231
72
55
43
2
751
3,904 (354)
ECG = electrocardiogram
*Categories added to the critical incident list of the German Society of Anaesthesiology and Intensive Care
Table 5
Top ten most frequently reported critical incidents
Critical incident
Critical incident category
No of critical incidents (per 10,000 anesthetics; 99% CI) n = 3,904
Technical difficulties with regional anesthesia
Detriment / injury
445 (40; 36 to 6)
Hypotension
Cardiovascular
432 (39; 35 to 44)
Unexpected difficult intubation
Respiratory
216 (20; 16 to 23)
Hypovolemia
Cardiovascular
163 (15; 12 to 18)
Arrhythmia
Cardiovascular
143 (13; 11 to 16)
Hypoventilation / hypoxemia
Respiratory
137 (12; 10 to 16)
Circulatory arrest
Cardiovascular
109 (10; 8 to 13)
Organizational problem
Equipment / Organization
101 (9; 7 to 12)
Laryngospasm
Respiratory
99 (9; 7 to 12)
Allergic reaction
Miscellaneous
95 (9; 7 to 11)
CI = confidence interval
×
Critical incidents with (probable) permanent damage consisted primarily of respiratory and cardiovascular critical incidents. Forty-three (1.1% of all critical incidents) critical incidents led to the death of a patient receiving an anesthetic procedure; forty of those critical incidents comprised a cardiovascular incident ranging from arrhythmia to myocardial infarction (Table 6).
Table 6
Critical incidents with (probable) permanent damage or death as consequence
Critical incident
Permanent damage (per 10,000 anesthetics)
Death (per 10,000 anesthetics)
Respiratory
4 (0.4)
2 (0.2)
Impossible intubation
0
1 (0.1)
Aspiration
1 (0.1)
1 (0.1)
Hypoventilation / hypoxemia
1 (0.1)
0
Difficult ventilation
1 (0.1)
0
Other respiratory disturbances
1 (0.1)
0
Cardiovascular
41 (3.7)
40 (3.6)
Hypotension
3 (0.3)
0
Hypertension
1 (0.1)
0
Arrhythmia
0
3 (0.3)
Hypovolemia
12 (1.1)
17 (1.5)
Heart failure
4 (0.4)
4 (0.4)
Pulmonary embolism
1 (0.1)
1 (0.1)
Circulatory arrest
12 (1.1)
5 (0.5)
Myocardial infarction
5 (0.5)
5 (0.5)
Temporary ST-segmental changes
1 (0.1)
0
Hemodynamic instability due to sepsis
2 (0.2)
4 (0.4)
Other cardiovascular disturbances
0
1 (0.1)
Equipment / organization
1 (0.1)
0
Monitor of blood pressure
1 (0.1)
0
Detriment / injury
7 (0.6)
0
Teeth
6 (0.5)
0
Eyes
1 (0.1)
0
Medication
1 (0.1)
0
Intravenous injection given subcutaneously
1 (0.1)
0
Miscellaneous
1 (0.1)
1 (0.1)
Anaphylactic shock
0
1 (0.1)
Other
1 (0.1)
0
Total (per 10,000 anesthetics; 99% CI)
55 (5; 4 to 7)
43 (4; 3 to 6)
CI = confidence interval
Discussion
The voluntary and non-anonymous critical incident registration system in this study proved to be very effective (response rate 94.4%). This high response was achieved by way of a reminder in the AIMS for reporting during skin closure and an e-mail reminder after completion of the anesthetic procedure. Furthermore, the non-anonymous registration allowed feedback through a twice weekly complication meeting in which action regarding a critical incident was discussed and initiated, thereby encouraging clinicians to report critical incidents. In 3.5% (354 per 10,000 anesthetics; 95% CI, 343 to 365) of anesthetic procedures a critical incident was reported, which is similar to the incidence reported in children using the same methodology.23
The present voluntary and non-anonymous reporting system is unique and has its advantages and disadvantages. Voluntarily reported critical incidents may suffer from underreporting.3,24 Previous studies have shown a low level of compliance when voluntary reporting was compared with automatically detected critical incidents,25-27 and in a different study, an incidence of 28% was reached when researchers completed a retrospective evaluation of all anesthetic procedures.13 Nevertheless, the response rate in the present system was very high (94%), and the advantage of the present system is the fact that anesthesiologists reported only those critical incidents considered to be clinically relevant. The non-anonymous system of reporting may also cause underreporting because a reporter might refrain from reporting due to fear of consequences.6,10,24 Nevertheless, a strong advantage of non-anonymous reporting is the ability to discuss the critical incident with detailed information from the involved anesthesiologist, which can lead to a teaching moment.3
The reporting system used in this study was based on the 20-item complication list of the Netherlands Society of Anesthesiologists. This 20-item complication list was not sufficient for detailed analysis and required extension as 21.6% of reported events could not be classified within the original list and were reported as miscellaneous (Tables 1 and 4). Nevertheless, the limited number of items in the classification system of the Netherlands Society of Anesthesiologists and the large amount of critical incidents in the miscellaneous category might have induced underreporting of the items not in the original list. For example, some might judge certain events as a critical incident, while others might judge the same event as not being a critical incident, and vice versa.24,28 It could be argued that not every critical incident that we present is truly a critical incident, e.g., technical difficulties with regional anesthesia are an inevitable occurrence when performing regional anesthesia. Furthermore, for the present study, all critical incidents were reclassified retrospectively to allow detailed analyses, and lack of information may have caused misclassification.
Cardiovascular incidents (106 per 10,000 anesthetics), in particular hypotension (40 per 10,000 anesthetics), comprised the majority of critical incidents (Tables 3 and 5). Previous studies showed the same level of cardiovascular incidents,13,29 whereas some studies indicated that difficulty with airway management11,14,16,29,30 or wrong drug/wrong drug-dose/wrong drug-labelling14 was the critical incident that occurred most frequently. This variance in number and type of critical incident might be due to the diversity of methods in the reporting systems and differences in definitions. For example, closed claims studies report death (26%), nerve injuries (22%), and permanent brain damage (9%) as the most common complications.11
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The present study identified the most frequently reported and most severe anesthetic critical incidents in our hospital on which to base future improvements for patient safety. The technical difficulties with regional anesthesia (Table 5) are being addressed in part by implementation of ultrasound guidance,31 but we propose a thorough investigation to determine which regional technique results in the most technical difficulties. Furthermore, the administration of the wrong drug (Table 4) is being tackled by strictly double-checking medication before administration.32
In conclusion, the present study shows that the present reporting system in AIMS along with e-mail feedback leads to a very high response rate in reporting critical incidents. Even so, the complication lists of the Netherlands Society of Anesthesiologists proved to be too limited, and therefore, the present list of complications can be used as an alternative. Cardiovascular complications were reported most frequently.
Funding
Department only.
Conflicts of interest
None declared.
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Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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Stehen die Chancen auf eine Rückkehr der Spontanzirkulation nach Herz-Kreislauf-Stillstand bei manueller oder maschineller Beatmung besser? Und unterscheidet sich das neurologische Outcome nach der Reanimation? Das belgische Herzstillstand-Register liefert die Daten für einen direkten Vergleich zwischen Beutel und Beatmungsgerät.
Es ist nur eine Frage der Zeit, bis es zu einem Zwischenfall kommt und ein Behandlungsfehler passiert. Doch wenn Ärztinnen und Ärzte gut vorbereitet sind, schaffen es alle Beteiligten den Umständen entsprechend gut durch diese Krise.
Patienten, die von Ärztinnen behandelt werden, dürfen offenbar auf bessere Therapieergebnisse hoffen als Patienten von Ärzten. Besonders gilt das offenbar für weibliche Kranke, wie eine Studie zeigt.
Akuter Schwindel stellt oft eine diagnostische Herausforderung dar. Wie nützlich dabei eine MRT ist, hat eine Studie aus Finnland untersucht. Immerhin einer von sechs Patienten wurde mit akutem ischämischem Schlaganfall diagnostiziert.
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