Critical incident reporting in an anaesthetic department quality assurance programme

TLDR

The critical incident technique was added to the quality assurance program of a major Hong Kong teaching hospital’s anaesthetic department. In one year, 125 incidents were reported from over 16,000 anaesthetics, most involving airway, breathing, or drug administration errors—80 % due to human error—primarily at induction or during anaesthesia, with half detected by anaesthetists and a third by monitoring equipment, leading to increased vigilance and improvements but still persisting incidents, and revealing issues beyond case and peer reviews.

Abstract

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.