Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore.
Singapore Med J. 2013 Feb;54(2):69-74. doi: 10.11622/smedj.2013027.
This study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore.
Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter.
A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children.
Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.
本研究报告了我们在新加坡一家儿科教学医院，对 2000 年至 2010 年期间儿科麻醉中观察到的审核和关键事件的经验。
通过审核表前瞻性地收集了与患者人口统计学、麻醉期间和围手术期实践和关键事件相关的数据，随后进行回顾性分析。
在研究期间进行的 75331 次麻醉中，共记录了 2519 起事件。报告了 9 例死亡。报告的大多数事件是呼吸关键事件（n=1757，69.8%），其次是心血管事件（n=238，9.5%）。关键事件的危险因素包括年龄小于 1 岁，以及早产儿和前早产儿。
关键事件报告具有价值，因为它提供了对系统的深入了解，并有助于识别主动和系统错误，从而制定有效的预防策略。通过营造和维持鼓励报告的环境，我们多年来保持了较高且一致的报告率。所有临床医生都应将关键事件分析的教学视为提高患者安全的重要工具。
