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Anesthesia: Essays and Researches
Original Article
Critical incidents during anesthesia in a developing country: A retrospective audit Amucheazi A. O., Ajuzieogu O. V. Department of Anaesthesia, College of Medicine University of Nigeria, Enugu campus, Nigeria Corresponding author: Dr. Amucheazi A. O., Department of Anaesthesia, College of Medicine University of Nigeria, Enugu campus, Nigeria. E-mail:
[email protected] Anesth Essays Res 2010, 4:2: 64-9
Abstract 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 4th and 5th 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.
Key words: Anesthesia, critical incidents, documentation, safety
INTRODUCTION
and no help available for proper intervention.
Adverse events occur in any area of medicine, more so in anesthesia. This may be due to errors in patient management, deviation from the standards of practice Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.73508
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When these incidents occur, the analysis of these is important, but not as a means of apportioning blame. Rather, they serve as a window on the system, a basis for training, simulation, and the improvement in standards of anesthesia care.[1] Also, the sharing and discussion of critical incidents would help to evolve new policies to prevent recurrences.[2]
MATERIALS AND METHODS From January 1 to December 31, 2008, the anesthetic records of all patients who had undergone either general or regional anesthesia at the University of Nigeria 64
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Anesthesia: Essays and Researches; 4(2); Jul-Dec 2010
Amucheazi and Ajuzieogu: Critical incidence in Anesthesia
Teaching Hospital, Ituku-Ozalla, were reviewed on a case by case basis for documented intraoperative critical incidents in this retrospective study. These deaths were further analyzed to identify contributing aspects of anesthetic procedure, operation and patient’s comorbidity. The overall mortality rate was determined from the total number of anesthetics and deaths. The perioperative deaths were assigned to one of the three groups: related to anesthesia (anesthesia was the major contributive factor), partially related to anesthesia and most probably unrelated to anesthesia. All documented critical incidents occurring in the time frame were retrospectively and anonymously collected. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anesthetists were noted. Basic safety monitoring in all patients included continuous electrocardiogram display, noninvasive blood pressure, capnography and pulse oximetry. The data collected were subjected to analysis using the SPSS software
RESULTS During the 1-year study, 1536 patients were administered anesthetic agents. Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. Critical incidents were reported but with complete recovery in 51 (94.4%) and mortality in 3 (5.6%) cases. Distribution of critical incidents was somewhat different in males and females (46.3 and 53.7%, respectively), with a maximum incidence in 30–39 and 40–49 year age group (20%). Forty-six (85.2%) had elective surgery while eight (14.8%) had emergency procedures [Table 1]. Majority of the critical incidents occurred in ASA grade I and II (60–65%) patients as compared to ASA III and IV patients [Figure 1]. The frequency of critical incidents was maximum in patients with no pre-existing systemic involvement (n=69, 61.61%), followed by cardiovascular (n=19, 16.96%) and
Three mortalities (1 per 512) were registered among the patients of ASA I–III physical status and eight mortalities were registered in the early postoperative period. Ratio of preoperative mortalities among the elective and emergency operations was 3:0. Of the three deaths, two were associated with hypoxic injury due to loss of airway and aspiration in adult and pediatric patients, respectively; the other one was due to intraoperative hemorrhage and the resultant unavailability of banked blood. Incidents occurred more frequently in patients who received general anesthesia (90%). Critical incidents occurred most commonly during the maintenance phase (75%) and least at the stage of extubation (50%) which were being conducted independently by resident doctors with 1–5 years experience. There was no indication of stress among the anesthetists conducting the cases. The critical incidents occurred at the period when workload of the anesthetists was less than 12 hours over a 24-hour period. There was no report of contributing factors like haste and distraction, but there was lack of help at such times.
DISCUSSION Whereever humans work, failures inevitably do occur.[3] These errors are often identifiable and repetitive, so they can be analyzed and classified.[4] Accurate analysis of critical incidents requires on the spot assessment and or in depth reporting in order to determine the etiology and develop preventive strategies. In the event of lack of a standard definition and with inaccurate data, there is paucity of assessment. Regarding the major areas of risks in anesthesia, the most valuable source of information can be derived from the ASA Closed Claims Project Database and the National Confidential Enquiry into Perioperative Deaths (NCEPOD) reports.[5,6] Despite arguments by Largesse about the current opinion that anesthesia is measurably safer in these times, very serious events are becoming rarer in the population.[7] The outcome of critical incidents invariably will depend on the degree of insult, timely intervention and the patient’s baseline health status. Anesthesia-related mortality in most developed countries is now
