Among 12,606 anaesthesia-related incidents reported over 2 years, 22.5% resulted in little or moderate harm and 2.1% resulted in severe harm or death.
Observational (n=12,606)
Yes
Analysis of a UK national database reveals that while most anaesthesia-related incidents cause little to no harm, 2.1% result in severe harm or death, highlighting areas for safety improvement.
The incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12,606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.
Catchpole et al. (2008) conducted an observational in Anaesthesia-related incidents (n=12,606). Anaesthesia was evaluated on Nature, frequency and severity of incidents. Among 12,606 anaesthesia-related incidents reported over 2 years, 22.5% resulted in little or moderate harm and 2.1% resulted in severe harm or death.