Critical incident reporting in an anaesthetic department quality assurance programme

The critical incident technique was introduced as an additional form of quality assurance to an anaesthetic department of a major Hong Kong teaching hospital. In one year, 125 critical incidents were reported from over 16,000 anaesthetics. The most common incidents reported concerned the airway, breathing systems, and drug administration, with inadequate checking of equipment a frequent associated factor. Human error was a factor in 80% of incidents. Critical incidents were reported for the time during which the patient was under the anaesthetist's care. The majority occurred at induction or during anaesthesia, and were reported for all surgical subspecialties. Half of the incidents were detected by the anaesthetist and one third by monitoring equipment. Although there were improvements in anaesthetic care as a consequence of increased vigilance, critical incidents still occurred. Critical incident reporting highlighted problems not otherwise covered by case and peer reviews, and complemented our quality assurance programme.