A critical incident reporting system in anaesthesia

Abstract

Objective: To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Design: Cross sectional study. A critical incident was defined as ‘any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient’. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. Setting: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Subjects: Between May and October 2000, 62 completed critical incident forms were collected. Main Outcome Measures: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. Results: A total of 14165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14 165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, lary ngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57 %, oxymetry 90 % and ECG 100 %. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15 % died, 23 % were unplanned admissions to HDU while 62 % were discharged to the ward with little or no adverse outcome. Conclusion: Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.