Outcome of peri-operative critical incidents in anaesthesia-a prospective observational study

Since the advent of its modern history, the administration of anaesthesia has been identified as a perilous endeavour with distinct risks to the patient. Perioperative risk is multifactorial and depends on the interaction of anaesthesia, patient and surgery specific factors. An incident reporting system which would improve patient safety and allow front-end clinicians to have easy access for reporting an incident is the need of the hour. The present study aimed to evaluate the critical incidents attributable to anaesthesia and analyze factors or events leading to anaesthetic mortality in perioperative period. A one year prospective observational study was conducted in the tertiary care hospital. Anaesthesiologists, working in operation theatres, post operativewards, Intensive Care Units and High Dependency Units, were asked to report critical incidents in an anonymous and voluntary basis on an indigenously prepared “Critical Incident Reporting Form”. A total of 101critical incidents were reported out of which62.37% were attributed toanaesthesia related factors and 37.62% to surgical factors. Mortality was found in 10 cases among the reported critical incidents in which 6 mortalities were due to anaesthesia related factors again out of which 5 patients had pre-existing illness. Hence, anaesthesia factor was responsible for 10% (n=1) mortalities. Thus it was found that anaesthesia was not solely related to perioperative mortality and it could be concluded that criticalincident reporting system is an integral part of quality assurance where clinicians should be encouraged to report critical incidents without the fear of a punitive action.