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Critical incidents in paediatric anaesthesia: A prospective analysis over a 1 year period
Raylene Dias1, Nandini Dave1, Swapna Chiluveru1
1Department of Paediatric Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.
Insights
Critical incidents occurred in 8.9% of paediatric anaesthetics, with airway and respiratory events being most common. This study highlights the need for a national reporting system in India to improve patient safety.
Area of Science:
- Pediatric Anesthesiology
- Patient Safety
- Critical Incident Reporting
Background:
- Critical incident reporting systems are vital for identifying medical errors and developing preventive strategies.
- While many nations have established reporting systems, India lacks a centralized national system.
- This study addresses the need to understand critical event incidence in India's pediatric operating rooms.
Purpose of the Study:
- To determine the incidence of critical events during pediatric anesthesia.
- To identify the types and causes of critical incidents in a pediatric operation theatre (OT).
- To provide data for establishing institutional policy guidelines in India.
Main Methods:
- A prospective observational study was conducted over one year in a pediatric OT.
- 1206 children undergoing anesthesia were monitored intraoperatively and postoperatively.
- Data collected included incident details, patient demographics, harm level, and contributing factors.
Main Results:
- The incidence of critical events was 8.9% (108 out of 1206 patients).
- Airway and respiratory events (60%) were the most frequent, including laryngospasm-related desaturation.
- Cardiovascular events (11.1%) and medication errors (3.8%) were also noted, with severe harm in 10 incidents and 1 death.
Conclusions:
- Approximately 1 in 10 pediatric patients experienced a critical incident during anesthesia.
- The audit facilitated the development of institutional policy guidelines for patient safety.
- Establishing a national critical incident reporting system in India is recommended.
Background And Aims:
Critical incident reporting helps to identify errors and formulate preventive strategies. Many countries have existing national reporting systems. Such a system is yet to be established in India. We aimed to study the incidence of critical events in the paediatric operation theatre (OT) of our institute.
Methods:
We conducted a prospective observational study of all children receiving anaesthesia in paediatric OT over a period of 1 year. They were monitored intraoperatively as well as postoperatively, and critical incidents were noted in terms of date and time of incident, location (OT/post-anaesthesia care unit, clinical category, age of patient, degree of patient harm resulting from the incident, description of what happened and duration of surgery. Percentage incidence of critical events was calculated.
Results:
A total of 1206 children received an anaesthetic during the study. Incidence of critical events was 8.9% (108). Airway and respiratory events were the maximum recorded accounting for 60 (55%) incidents. There were 43 cases of oxygen desaturation out of which 21 were attributable to laryngospasm. Cardiovascular events were 12 (11.1%). Medication-related incidents were 4 (3.8%). Severe harm was reported in ten incidents, and 1 death was reported. A few uncommon incidents like change in voice following use of a cuffed endotracheal tube and post-operative acute renal failure requiring haemodialysis were noted.
Conclusion:
Incidence of critical incidents was almost one for every ten patients, and the audit helped us establish policy guidelines in our institution.
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