Critical incidents during anesthesia: prospective cohort study

Abstract

Abstract Background: a critical incident reporting and analysis is one of the key components of patient safety in anesthesiology. The aim of this study was to determine the frequency and characteristics of critical incidents during anesthesia, main causes and factors involved, influence on patients outcomes, prevalence of emergency notification and response systems. Methods: A multicenter prospective cohort study was conducted at the clinical departments of Bogomolets National Medical University (postgraduate department of surgery, anesthesiology and intensive care)during the period from 1 June 2021 to 1December2021. 13 hospitals from different Ukraine regions took part in the study. The study design was approved by the Bogomolets National Medical University (NMU)ethics committee, protocol #148, 07.09.2021. Results: The mean incidence of critical incidents during anesthesia in Ukraine was 0.94% (ranging from 0.04% to 3.4% on different sites). Most common incidents were related to the respiratory system: difficult airway (26.8%), reintubation (6.4%), oxygen desaturation (13.8%); cardiovascular system: hypotension (14.9%), tachycardia (6.4%), bradycardia(11.7%), hypertension (5.3%), collapse (3.2%); massive hemorrhage (17%). Surprisingly emergency situations often occurred while treating patients considered low-risk as assessed by an anesthesiologist (ASA II – 57.4%) and during planned surgical interventions (63.2%). Among common reasons that could lead to the incident, the treating physicians have identified: individual patient features (47%), surgical tactics (18%), anesthesia (16%) and human factor (12%). The most frequent shortcomings of the patient management were: preoperative assessment (44%), incorrect interpretation of the patients’ state (33%), faulty manipulation technique (14%), miscommunication (13%) and delay in emergency care provision (10%). Furthermore, 48% of cases, as judged by participating physicians, were preventable and the consequences of another 18% could be minimized. The consequences of the emergency situations were insignificant in over a half of the cases, but in 24.5% have led to protracted hospital stay with 30 patients (16%) being urgently transferred to the ICU and 12 (6.5%) dying in the hospital.34.8% of reported incidents were not documented otherwise and 16.3% were not reported to the chief of department. The emergency situation was followed by a detailed examination within the department in 58.1% of cases with 6.5% resulting in a permanent policy change. Conclusion: Critical incidents during anesthesia occur rather often and impact the treatment results significantly. Notification, registration and analysis of such incidents are not being performed systematically, which proves to be one of the major threats to patient safety during anesthesia. Study registration: NCT05435287, clinicaltrials.gov, 28/06/2022