An analysis of critical incidents in a teaching department for quality assurance. A survey of mishaps during anaesthesia.

A prospective survey was conducted from April 1984-January 1985 and April 1985-January 1986 to study the frequency of critical incidents and factors associated with them. Eighty-six mishaps were reported in the first period, the majority of which were because of human error (80.3%); the most common were the transmission of gases and vapours and errors in drug administration. Factors frequently associated with these mishaps were failure to perform a normal check and lack of familiarity with equipment or technique. An anaesthesia equipment checklist was incorporated in the survey during the second period and 43 mishaps were reported. This decrease in incidence may have resulted from the anaesthesia apparatus checklist, awareness of mishaps since they were discussed regularly at departmental meetings, and new anaesthesia machines (eight older machines were replaced during the first period and 11 at the beginning of the second).