Statistics out of 132 reported critical incidents
Who reported (n = 132):
| n | % | |
| Resident | 42 | 31% |
| Consultant | 79 | 60% |
| Nurse | 11 | 9% |
How were you related to the incident (n = 127):
| n | % | |
| Helping | 17 | 14% |
| Responsible for care | 43 | 34% |
| Primary provider of anaesth. care | 67 | 52% |
Type of procedure (n = 132):
| n | % | |
| Elective | 101 | 77% |
| Emergency | 31 | 23% |
Anaesthetic technique (n = 132):
| n | % | |
| General anaesthesia | 100 | 75% |
| Combined general-regional | 7 | 6% |
| MAC | 3 | 2% |
| Regional anaesthesia | 22 | 17% |
ASA-class: median 2, min 1, max. 4
ASA-class in detail
| Class 1 | 13 |
| Class 2 | 38 |
| Class 3 | 20 |
| Class 4 | 13 |
| Class 5 | 1 |
Experience of the primary provider of anaesthetic care: 8.1 +- 7.3 years
Details of the experience of the primary provider of anaesthetic care: n = 46
| experience | ||
| Resident | n = 21 | 5.1 +- 3 years |
| Nurse | n = 20 | 11.75 +- 7.3 years |
| Consultant | n = 5 | 4.4 +- 2.9 years |
When did the incident happen (n = 132):
| n | % | |
| Before induction | 8 | 6% |
| During induction | 39 | 29% |
| During maintenance | 61 | 46% |
| During emergence | 11 | 8% |
| During recovery | 4 | 3% |
| Same day post-OP | 8 | 6% |
| During in-hosp. transfer | 1 | 1% |
What happened (n = 132):
| n | % | |
| Respiratory event | 38 | 29% |
| Wrong drug/dose | 37 | 28% |
| Circulatory event | 21 | 16% |
| Pharmacologic event | 5 | 4% |
| Positioning event | 5 | 4% |
| Regional anaesthesia event | 8 | 6% |
| Technical event | 7 | 5% |
| Team event | 3 | 2% |
| Misc. | 8 | 6% |
Outcome of the event (n = 132):
| n | % | |
| Not affected by incident | 95 | 72% |
| Patient dissatisfaction | 9 | 7% |
| Prolonged hosp. | 8 | 6% |
| Unplanned ICU-admission | 7 | 5% |
| Minor morbidity | 2 | 2% |
| Major morbidity | 6 | 5% |
| death | 5 | 4% |
What led to the incident (more than one factor per incident was allowed):
| n = 266 | % |
|||
| Personal factors | 88 | 33 | 64 | 83 |
| No check | 34 | 13 | ||
| Fatigue & workload | 47 | 18 | ||
| Team & communication factors | 53 | 20 | ||
| Patient condition | 15 | 6 | ||
| Environmental factors | 22 | 8 | ||
| Technical problem | 7 | 3 | ||
What would you suggest for prevention (n = 62):
| n | % | |
| Better training | 16 | 25% |
| Better communication | 15 | 24% |
| Development of algorithms | 6 | 10% |
| Abandoning of old routine | 7 | 11% |
| More discipline with checklists | 5 | 8% |
| Better working conditions | 3 | 5% |
| Better supervision | 2 | 4% |
| Improved arrangement of drugs | 3 | 5% |
| Improved equipment | 2 | 4% |
| Additional monitoring | 1 | 2% |
| Better maintenance of existing equipment | 1 | 2% |
| Better organisation | 1 | 2% |
Severity of the incidents (acc. to the Salisbury severity index):
| Category | Squares of severity-score (mean) |
| Circulatory | 9.92 |
| Respiratory | 5.63 |
| Wrong drug/dose | 4.61 |
| Pharmacologic | 2.8 |
| Positioning | 4.0 |
| Regional anaesthesia event | 5.8 |
| Technical failure | 1.75 |
1 = transient abnormality, unaware to the patient
...
5 = death
The square of each individual value was calculated in order to reinforce the more severe events. An event with a severity-score of 5 will end up with 25 (square of 5). The mean of these reinforced score was then calculated for each category.
Recoveries (n = 167; more than one factor was allowed per incident)
| Category | % |
|
| Exemplary communication | 31 | 77 |
| Human recoveries | 46 | |
| Existance of rules | 7 | |
| Technical recoveries | 16 | |
Adding communication to human recoveries gives in total a set of 77% of appropriate human performance.