Incidents in Obstetric Anaesthesia and Analgesia: An Analysis of 5000 AIMS Reports

Abstract

We aimed to explore the first 5000 incidents reported to the Australian Incident Monitoring Study (AIMS) involving anaesthesia for obstetric patients and found 203 such incidents. Analysis and classification identified seven main incident groups; regional anaesthetic techniques (33%), anaesthetic equipment problems (13%), “wrong drug” errors (10%), other drug-related problems (16%), difficult/failed intubation (9%), problems with the endotracheal tube (9%) and other problems (10%). When compared to the incidents in the main database, obstetric cases were found to be over-represented with respect to accidental dural puncture, post dural puncture headache, failed intubation in emergency situations and the incidence of certain types of “wrong drug” error. The implications of these reports regarding safe practice of obstetric anaesthesia are discussed.