Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Incident reporting is a reliable quality assurance tool, frequently used in anaesthesia to identify errors. It was introduced in anaesthesia by Cooper in 1978 and since then several institutions have adopted this system to find adverse events and near misses. We think that the incident reporting would be more beneficial for prolonged and technically complex procedures like paediatric cardiac surgery. Methods: All paediatric CHD patients scheduled for cardiac surgery were included in this audit. Thoracic and general surgery patients were excluded. Any event in preoperative area, induction room, operating room and during transfer to cardiac ICU was documented in a predesigned proforma by resident/consultant. This proforma included information regarding demographics, the type and severity and responsible factors for the event. Results: 134 patients were included in this two and half years audit. 88 patients were male (65.7%) and 46 (34.3%) were female. The age of the patients ranged from one day to 15 years. Total 105 incidents were noticed in 61 patients. 46 incidents were declared as major events which were potentially serious while 59 events were of minor nature. Cuffed endotracheal tube was used in 73% patients. The majority of events occurred in the pre-bypass period. Most of the incidents were related to cardiovascular system (73%), followed by pharmacological incidents. Human factors (74%) were mainly responsible for the incidents. Conclusion: Incident reporting is a reliable and feasible method of improving quality care in developing countries. It helps in identifying areas which need improvement and helps in developing guidelines to improve safety.