Critical incident analysis: Equip to avoid failure

Area of Science:

• Anesthesiology
• Patient Safety
• Risk Management

Background:

• Difficult airway management is a critical aspect of perioperative care.
• Temporary equipment failure poses a significant risk during anesthesia.
• Human factors influence safety in the operating theatre environment.

Purpose of the Study:

• To investigate a critical incident involving temporary equipment failure during difficult airway management.
• To analyze risk management and incident reporting in this context.
• To identify recommendations for improving anesthetic practice.

Main Methods:

• Root cause analysis (RCA)
• Fishbone technique (Ishikawa diagram)
• Analysis of human factors in the operating theatre

Main Results:

• Identified temporary equipment failure as a critical incident.
• Highlighted the importance of risk management and incident reporting.
• Underscored the role of human factors in perioperative adverse events.

Conclusions:

• Recommendations for risk reduction in airway management.
• Emphasized the need for increased vigilance in checking vital airway equipment.
• Proposed improvements for anesthetic practice to prevent future incidents.