Choy Y C, Lee C Y, Inbasegaran K
Department of Anaesthesiology, Faculty of Medicine, Universiti Kebangsaan Malaysia.
Med J Malaysia. 1999 Mar;54(1):4-10.
Critical incident reporting is a useful quality improvement technique for reducing morbidity and mortality in anaesthesia. This study analyses 93 cases in Kuala Lumpur Hospital from July 1995 to January 1997. The main incidents during anaesthesia in this study were airway incidents. While human error was identified as the main factor contributing to the occurrence of adverse incidents. Critical incident monitoring plays an important role in identifying potential problems, which may lead to disaster. The findings from this report of the anaesthesia incident monitoring study continued to indicate the occurrence of similar problems seen in an earlier report. The identification of common incidents can be used to identify risk factors and minimise repetition of such incidents.
危急事件报告是一种用于降低麻醉相关发病率和死亡率的有效质量改进技术。本研究分析了1995年7月至1997年1月吉隆坡医院的93例病例。本研究中麻醉期间的主要事件是气道事件。人为失误被确定为导致不良事件发生的主要因素。危急事件监测在识别可能导致灾难的潜在问题方面发挥着重要作用。这份麻醉事件监测研究报告的结果继续表明，在早期报告中也出现过类似问题。识别常见事件可用于识别风险因素，并尽量减少此类事件的重复发生。
