Untoward incident reporting in obstetric anaesthesia: a 6-month prospective study in Northern Ireland

The marked reduction in the number of cases related to the provision of anaesthesia, included in the triennial Reports on Confidential Enquiries into Maternal Deaths in the UK, may limit the educational value of such reports for anaesthetists in the future. The collection, analysis and reporting of untoward events related to obstetric anaesthesia may provide an additional method of highlighting areas of clinical practice that could be improved. We report on a prospective study to identify such untoward incidents related to obstetric anaesthesia in the well circumscribed population of anaesthetists involved in this specialty in Northern Ireland. In total, 22 incidents were reported during the 6-month period of the study. A brief summary of each event is included along with a more detailed description from a sample of the reports. The advantages and disadvantages of untoward incident reporting are discussed, with recommendations made for a future survey.