[Prioperative adverse events: critical reading of the data registry used in the surgery department of military hospital Moulay Ismail, Meknes].

INTRODUCTION

Despite significant progress made in the field of safety in anesthesia, morbidity (serious or not, completely or partially related to anesthesia) remains common and no health practitioner is immune from accidents. In the current context where priority is given to training programmes, to quality and safety improvement in health care, the occurrence of an anesthesia-related accident in the surgery department is an extremely traumatic event. The fear of prosecution, the emotional context make it difficult to manage. For this reason, it must be codified according to Department protocols, based on three main axes of management: patient victim, medical and paramedical staff involved and accident analysis to prevent its recurrence.

METHOD

In order to improve health care quality in surgery department we have implemented a continuously updated data registry containing the incidents and accidents occurred either in the operating room or in the post-interventional surveillance room A first reading was made on the occasion of Post Doctoral Training (JEPU) in Fez (Morocco) organized in partnership with the JEPU of the Pitié Salpêtrière in Paris at the School of Medicine and Pharmacy of Fez under the theme: «Critical Situations In Surgery Department» 17,18 April 2015.

RESULTS

1761 patients were admitted to different operating rooms, 96 in the endoscopy room and 17 under sedation in diagnostic radiology. 29 patients (1.64%) reported a perioperative incident and/or a perioperative accident. Most of the adverse events occurred during surgery (58.6%). 28.6% of cases in the immediate post-operative period or in the post-interventional surveillance room. The most frequent complications were respiratory (34%) or cardiovascular (31%). We recorded 5 perioperative deaths (mortality rate of 28%) Determining the cause is not always obvious. The human factor is responsible for 24% of incidents.

CONCLUSION

This observation highlights the different adverse events which have been recorded since the establishment of the data registry 6 months before. We offer a critical reading of this data registry for the sole purpose of improving our practices with a view to strengthening safety during anaesthesia.