Critical incident reports in adults: an analytical study in a teaching hospital

Self-auditing is important to improve the standard of care. In a previous study (1991--1997), we reported human error and equipment factor as the two major causes leading to critical incidents. This study analyzes the computerized database and the medical records of 71 critical incidents reported in the Department morbidity and mortality meeting between 1998--2002, in an attempt to identify factors that have led to critical incidents and compare them with our previous report.

We use a standard form where factors which lead to critical incidents are identified such as: anesthesia providers, patient's characteristics, type of anesthesia and others. The form includes a section for the reporter to narrate the whole incident.

Seventy-one incident reports in adult patients were studied. In 35.3% consultants reported the incidents, while 64.7% were reported by residents. Most of the incidents were reported in patients undergoing emergency surgery (P = 0.0034) and with physical status III-IV (P = 0.008). Incidents due to circulatory events were 33.8%, while respiratory incidents were 35.2%. The majority of incidents were due to human error (38%), lack of team communication (23.9%), patient condition (10%) and technical problems, (19.7%). Suggestions for prevention of incidents were, better training 29.2%, better communication 20.3%, developing of algorithms 12.6%, checklists 10.2%, better supervision 15.2%, improved equipment 6.3%, improved arrangement of drugs 5.2% and for additional monitoring 1%.

Emergency surgery and patient ASA physical status III-IV were significant predictors of critical incident reports. Analysis of anesthesia related problems may contribute to improved preventive strategies.