TITLE:
Critical Incident Reported in an Obstetric Unit of a Tertiary Care Hospital of a Developing Country, over a Period of Two Years
AUTHORS:
Shemila Abbasi
KEYWORDS:
Obstetric, Anesthesia, Critical Incident, Quality Improvement, Adverse Events, Outcomes
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.7 No.12,
November
30,
2017
ABSTRACT: Introduction: A lot of literature is available on critical
incidents and near misses but specialty based critical incidents are very scanty.
Aim: In this audit, we aimed
to report critical incident and near misses during conduct of obstetric anesthesia
over a period of two years. Methodology: Critical incident forms were collected,
entered, analyzed and categorized on the basis of American Standards Association
(ASA), phase of incidents, system involved, and type of errors, outcome and action
taken. Human error was further categorized on the basis of their contributing factor marked in form.
Results: During the reporting period, 5511 anaesthetics were administered and 55 reports were received out of which
53 reports were included in analysis. Fifty three reports were divided into 33 critical
incidents and 20 near misses. Out of 33 critical incidents, 54.5% involved CVS system
and musculoskeletal system, followed by neuromuscular (n = 5), drug related (n = 4), airway/respiratory
system (n = 2), central nervous system (n = 2) and renal system (n = 1). Forty five
incidents possess no untoward effect while 7 led to minor and only one to severe
physiological disturbance. Human errors were (n = 30) 57% reports and failure to
check was the main contributory factor. Conclusion: Critical incidents reporting
needs to be introduced in sub-specialties
at departmental, national and international level. Checking of equipment, medication
and anesthesia machine must be part of regular checks in elective and emergency
cases.