A prospective audit of XXXX in anaesthesia in a university teaching hospital.

@entity1 @entity3124 @entity1167
INTRODUCTION: We aimed to reduce mortality and morbidity in anaesthesia by identifying common factors contributing to critical incidences and 'near misses'. MATERIALS AND METHODS: We carried out a prospective survey over a 2-year period from May 1999 to April 2001 of all reported @entity3124 in @entity1 undergoing anaesthesia. @entity3124 were reported anonymously, using the Anaesthetic Incident Monitoring Study form. This consisted of structured questions with tick box answers. Completed forms were reviewed and after open discussion with the department, preventive strategies and guidelines were developed and introduced. RESULTS: A total of 116 critical incidences were reported in 108 @entity1 . These are events that have resulted or could have resulted in an adverse outcome for the @entity1 . Airway incidences were the commonest incidence reported (33.6%), followed by pharmacological problems like wrong drug or dose (28.4%). These occurred most often during maintenance and recovery from anaesthesia largely due to @entity1 factors like inattention, haste and failure to check equipment. They were preventable in 76% of cases. As a consequence, 33.6% of incidents resulted in @entity1167 or major physiological change. There was no adverse outcome in 36.2%. From a review of the critical incident reporting, organisation of manpower was improved to ensure adequate supervision of junior staff. Checking of equipment and drug before use was constantly emphasized. CONCLUSION: Critical incident reporting is a useful tool for quality assurance programmes. It analyses @entity1 and systems problems to ensure improved @entity1 care.
