Critical incidents in paediatric anaesthesia: A prospective analysis over a 1 year period

BACKGROUND AND AIMS: Critical incident reporting helps to identify errors and formulate preventive strategies. Many countries have existing national reporting systems. Such a system is yet to be established in India. We aimed to study the incidence of critical events in the paediatric operation theatre (OT) of our institute. METHODS: We conducted a prospective observational study of all children receiving anaesthesia in paediatric OT over a period of 1 year. They were monitored intraoperatively as well as postoperatively, and critical incidents were noted in terms of date and time of incident, location (OT/post-anaesthesia care unit, clinical category, age of patient, degree of patient harm resulting from the incident, description of what happened and duration of surgery. Percentage incidence of critical events was calculated. RESULTS: A total of 1206 children received an anaesthetic during the study. Incidence of critical events was 8.9% (108). Airway and respiratory events were the maximum recorded accounting for 60 (55%) incidents. There were 43 cases of oxygen desaturation out of which 21 were attributable to laryngospasm. Cardiovascular events were 12 (11.1%). Medication-related incidents were 4 (3.8%). Severe harm was reported in ten incidents, and 1 death was reported. A few uncommon incidents like change in voice following use of a cuffed endotracheal tube and post-operative acute renal failure requiring haemodialysis were noted. CONCLUSION: Incidence of critical incidents was almost one for every ten patients, and the audit helped us establish policy guidelines in our institution.