An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006-2008.

OBJECTIVES/AIMS: We aimed to identify and analyze critical incidents relating to pediatric anesthesia from the National Reporting and Learning System (NRLS) in England and Wales.

BACKGROUND

Critical incident reporting plays a key role in learning from problems and so enhancing patient safety. There has been no previous analysis of pediatric anesthetic incidents in the NRLS.

METHODS

We obtained potentially relevant records from the UK National Patient Safety Agency. Eligible incidents were classified according to patient age, degree of harm sustained, and clinical category.

RESULTS

A total of 606 incidents met the inclusion criteria. Six deaths were reported and 48 incidents resulted in severe harm. In many reports, sufficient detail was lacking for a full understanding of what had happened. However, the broad focus of the NRLS revealed a wide spectrum of clinical and organizational incidents relating to pediatric anesthesia. Medication issues predominated (35.6%), notably inadvertent duplication of dosing in operating theater and ward. Airway/ventilation incidents formed 18.8% of the total, cardiovascular incidents 5.9%, and equipment-related incidents (failure or unavailability) 15.7%. Communication and organizational problems made up 8.6% of reports.

CONCLUSIONS

We make a number of recommendations for practice. In addition, anesthetists should be encouraged to take ownership and contribute high-quality descriptions of incidents to national systems.