Figure 1
Figure 2
Figure 3
Monitoring equipment used during anesthesia in 2,206 incident reports
| Monitoring equipment | n (%) |
|---|---|
| Pulse oximeter | 2188 (99.2) |
| Electrocardiograph | 2180 (98.8) |
| Sphygmomanometer (noninvasive blood pressure) | 2144 (97.2) |
| Capnometer | 1789 (81.8) |
| Spirometer | 1005 (45.6) |
| End tidal gas analyzer | 820 (37.2) |
| Invasive arterial pressure monitor | 531 (24.1) |
| Thermometer | 476 (21.6) |
| Central venous pressure catheter | 402 (18.2) |
| Oxygen analyzer | 391 (17.7) |
| Pulmonary arterial pressure analyzer | 37 (1.7) |
| Echocardiograph | 25 (1.1) |
| Electroencephalograph | 12 (0.5) |
| Cardiac output monitor | 7 (0.3) |
Phase and location of occurrence of incidents (N = 2,206 reports)
| n (%) | |
|---|---|
| Phase | |
| Preinduction | 112 (5.1) |
| Induction | 496 (22.5) |
| Maintenance | 761 (34.5) |
| Emergence | 152 (6.9) |
| Recovery | 224 (10.2) |
| Postoperative 24 h | 381 (17.3) |
| Location | |
| Induction room | 15 (0.7) |
| Operating room | 1433 (65.0) |
| Recovery room | 235 (14.6) |
| Intensive care | 167 (7.6) |
| Delivery room | 3 (0.1) |
| Ward | 239 (10.8) |
| Imaging unit | 10 (0.5) |
| During transportation | 14 (0.6) |
| Others (gastrointestinal endoscopy unit, | 6 (0.2) |
Factors contributing to the incidents (N = 2,206 reports)
| Contributing factors | n (%) |
|---|---|
| Noncompliance with surgical safety checklists | 35 (1.6) |
| Inappropriate decision | 307 (13.9) |
| Inadequate knowledge | 125 (5.7) |
| Inexperience | 630 (28.6) |
| Haste | 188 (8.5) |
| Fatigue | 11 (0.5) |
| Inadequate personnel | 24 (1.1) |
| Communication defect | 86 (3.9) |
| Not familiar with environment | 6 (0.3) |
| Emergency condition | 418 (18.9) |
| Inadequate preanesthetic evaluation | 333 (15.1) |
| Inadequate preanesthetic preparation | 116 (5.3) |
| Inadequate equipment | 35 (1.6) |
| Inefficient equipment/monitoring | 55 (2.5) |
| Monitor not available | 8 (0.4) |
| Error in drug label | 29 (1.3) |
| No recovery room | 4 (0.2) |
| Blood bank problems | 21 (1.0) |
Factors minimizing incidents in 2,206 incident reports
| Factors | n (%) |
|---|---|
| Compliance with surgical safety checklists | 105 (4.8) |
| Having experience | 995 (45.1) |
| Experienced assistant | 736 (33.4) |
| Vigilance | 1150 (52.1) |
| Adequate personnel | 32 (1.5) |
| Effective supervision | 129 (5.8) |
| Effective communication | 186 (8.4) |
| Improvement of training | 75 (3.4) |
| Adequate equipment | 83 (3.8) |
| Adequate maintenance | 44 (2.0) |
| Equipment check up | 57 (2.6) |
| Adequate monitoring equipment | 85 (3.9) |
| Comply to practice guidelines | 189 (8.6) |
| Other | 58 (2.6) |
Critical incidents classified by perioperative periods for 2,206 incident reports and overall incidence
| Critical incidents (N = 2,206 reports) | Overall | ||||
|---|---|---|---|---|---|
| Operative period n (%) | Postanesthesia care unit n (%) | Postoperative 24h n (%) | Total (N = 2,206) n (%) | Incidence (95% Cl) per 10,000 | |
| Pulmonary aspiration | 30(1.4) | 1(0.1) | 2(0.1) | 33(11.5) | 1.36(0.89,1.82) |
| Suspected pulmonary embolism | 14(0.6) | 4(0.2) | 1(0.0) | 17(0.8) | 0.51(0.27,0.75) |
| Esophageal intubation | 184(8.3) | – | – | 184(8.3) | 8.51(7.28,9.74) |
| Endobronchial intubation | 24(1.1) | – | – | 24(1.1) | 1.11(0.67,1.55) |
| Oxygen desaturation | 342(15.5) | 119(5.4) | 17(0.8) | 465(21.1) | 13.95 (12.69,15.00) |
| Reintubation | 63 (2.9) | 113(5.1) | 66(3.0) | 240(10.9) | 11.10(9.70,12.51) |
| Difficult intubation | 172(7.8) | 2(0.1) | – | 173 (7.8) | 8.00(6.81,9.19) |
| Failed intubation | 16(0.7) | – | – | 16(0.7) | 0.74(0.38,1.10) |
| Total spinal block | 2(0.1) | – | – | 2(0.1) | 0.32 (–0.12,0.77) |
| Awareness during general anesthesia | – | – | 10(0.5) | 10(0.5) | 0.41(0.16,0.67) |
| Coma/cerebrovascular accident/convulsion | 8(0.4) | 11(0.5) | 39(1.8) | 53 (2.4) | 1.59(1.16,2.02) |
| Nerve injury | 5(0.2) | 1(0.1) | 16(0.7) | 21(1.0) | 0.63(0.36,0.90) |
| Transfusion mismatch | 4(0.2) | 3 (0.2) | – | 7(0.3) | 0.21(0.05,0.37) |
| Suspected myocardial infarction/ischemia | 20(0.9) | 4(0.2) | 14(0.6) | 34(1.5) | 1.02(0.68,1.36) |
| Severe arrhythmia | 467(21.2) | – | – | 467(21.2) | 14.01 (12.74,15.29) |
| Cardiac arrest within 24 h | 255(11.6) | 9(0.4) | 272(12.3) | 519(23.5) | 15.58(14.24,16.91) |
| Death within 24 h | 107(4.9) | 5(0.3) | 330(15.0) | 442(20.0) | 13.26(12.03,14.50) |
| Anaphylaxis/anaphylactoidreaction/allergy | 67(3.0) | 14(0.6) | 1(0.0) | 79(3.6) | 2.37(1.85,2.89) |
| Drug error | 104(4.7) | 1(0.1) | 2(0.1) | 107(4.9) | 3.21(2.60,3.82) |
| Equipment malfunction/failure | 47(2.1) | – | 2(0.1) | 4.7 (2.1) | 1.41(1.01,1.81) |
| Anesthesia personnel hazard | 2(0.1) | 15 (0.7) | – | 17(0.8) | 0.60(0.34,0.97) |
| Suspected emergence delirium | 2(0.1) | 15 (0.7) | – | 17(0.8) | 0.60(0.34,0.97) |
| Wrong patient/site/surgery | 6(0.3) | – | – | 6(0.3) | 0.18(0.04,0.32) |
Immediate and long-term (7-day) outcomes for 2,206 incident reports
| n (%) | |
|---|---|
| Immediate outcomes | |
| Complete recovery | 553 (25.1) |
| Death | 432 (19.6) |
| Major physiological change | 326 (14.8) |
| Respiratory | 207 (9.4) |
| Cardiovascular | 91 (4.1) |
| Neurological | 66 (3.0) |
| Cardiac arrest | 261 (11.8) |
| Unplanned intensive care unit admission | 163 (7.4) |
| Minor physiological change | 72 (3.3) |
| Prolonged emergence | 20 (0.9) |
| Awareness | 7 (0.3) |
| Unplanned hospital admission | 5 (0.2) |
| Other | 79 (3.6) |
| Long-term (7-day) outcomes | |
| Complete recovery | 265 (12.0) |
| Death | 249 (11.3) |
| Prolonged hospital stay | 144 (5.2) |
| Prolonged ventilator support | 132 (6.0) |
| Disability | 6 (0.3) |
| Vegetative stage | 6 (0.3) |
| Psychic trauma | 2 (0.1) |
| Other | 7 (0.3) |
Operation or operative site of surgery in 2,206 incident reports
| n (%) | |
|---|---|
| General surgery | 690 (31.3) |
| Orthopedic | 267 (13.0) |
| Neurosurgery | 168 (7.6) |
| Cardiac | 148 (6.7) |
| Gynecological | 137 (6.2) |
| Otorhinolaryngological | 127 (5.8) |
| Thoracic | 117 (5.3) |
| Urological | 111 (4.9) |
| Endoscopic | 85 (3.9) |
| C-section | 74 (3.4) |
| Vascular | 71 (3.2) |
| Ophthalmological | 69 (3.1) |
| Plastic | 47 (2.1) |
| Dental | 24 (1.1) |
| Intervention | 24 (1.1) |
| Minimally invasive | 19 (0.9) |
| Diagnostic | 8 (0.4) |
| Electroconvulsive | 2(0.1) |
| Radiotherapy | 2(0.1) |
Suggested corrective strategy for prevention of occurrence of incidents (N = 2,206 reports)
| Factors | n (%) |
|---|---|
| Compliance with surgical safety checklists | 114 (5.2) |
| Compliance with guidelines | 638 (28.9) |
| Additional training | 502 (22.8) |
| More manpower | 87 (3.9) |
| Improvement of supervision | 497 (22.5) |
| Improvement of communication | 209 (9.5) |
| More equipment | 76 (3.4) |
| Equipment maintenance | 59 (2.7) |
| Quality assurance activity | 452 (20.5) |
| Good referral system | 33 (1.5) |
| Other | 38 (1.7) |