Liu E H, Koh K F
Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074.
Ann Acad Med Singap. 2003 Nov;32(6):814-20.
We aimed to reduce mortality and morbidity in anaesthesia by identifying common factors contributing to critical incidences and 'near misses'.
We carried out a prospective survey over a 2-year period from May 1999 to April 2001 of all reported critical incidents in patients undergoing anaesthesia. Critical incidents were reported anonymously, using the Anaesthetic Incident Monitoring Study form. This consisted of structured questions with tick box answers. Completed forms were reviewed and after open discussion with the department, preventive strategies and guidelines were developed and introduced.
A total of 116 critical incidences were reported in 108 patients. These are events that have resulted or could have resulted in an adverse outcome for the patient. Airway incidences were the commonest incidence reported (33.6%), followed by pharmacological problems like wrong drug or dose (28.4%). These occurred most often during maintenance and recovery from anaesthesia largely due to human factors like inattention, haste and failure to check equipment. They were preventable in 76% of cases. As a consequence, 33.6% of incidents resulted in cardiac arrest or major physiological change. There was no adverse outcome in 36.2%. From a review of the critical incident reporting, organisation of manpower was improved to ensure adequate supervision of junior staff. Checking of equipment and drug before use was constantly emphasized.
Critical incident reporting is a useful tool for quality assurance programmes. It analyses human and systems problems to ensure improved patient care.
我们旨在通过识别导致严重事件和“险些失误”的常见因素，降低麻醉过程中的死亡率和发病率。
我们在1999年5月至2001年4月的两年期间，对所有报告的接受麻醉患者的严重事件进行了前瞻性调查。严重事件通过使用麻醉事件监测研究表格进行匿名报告。该表格由带有勾选框答案的结构化问题组成。对填写完整的表格进行了审查，并在与科室进行公开讨论后，制定并引入了预防策略和指南。
108例患者共报告了116起严重事件。这些事件已经或可能导致患者出现不良后果。气道事件是报告最多的事件（33.6%），其次是药物问题，如用药错误或剂量错误（28.4%）。这些事件最常发生在麻醉维持和苏醒期间，主要是由于人为因素，如注意力不集中、匆忙行事和未检查设备。76%的病例是可预防的。因此，33.6%的事件导致心脏骤停或重大生理变化。36.2%的事件没有不良后果。通过对严重事件报告的审查，改进了人力组织，以确保对初级工作人员进行充分监督。不断强调在使用前检查设备和药物。
严重事件报告是质量保证计划的有用工具。它分析人为和系统问题，以确保改善患者护理。
