A Critical Incident Reporting System In Anaesthesia

Abstract

The critical incident system is now well established as a concept and activity of a quality programme in anaesthesia. Most publications are from well resourced countries with little contribution from developing countries. When something goes wrong in the anaesthetic management of a patient, that event is the final outcome of a process that began some time before. The event may or may not be the ‘fault’ of the anaesthetist, but that the system (environment) in which he/she works, allows certain errors to occur without correction. Eventually, the cumulative or coincident effect of several such errors leads to the “something going wrong”. A critical incident system identifies such errors, alerts participants to the types of errors in the system, enabling corrective measures to be put in to place, rendering the environment safer. The Department of Anaesthetics and Critical Care Medicine, University of Zimbabwe Medical School has introduced a Critical Incident Reporting System as part of their quality programme. The audit presented here is a review of that process.