National Health Service (NHS) Grampian, Aberdeen, United Kingdom.
Department of Anaesthesia, Bahir Dar University, Bahir Dar, Ethiopia.
Pan Afr Med J. 2021 Apr 16;38:375. doi: 10.11604/pamj.2021.38.375.24711. eCollection 2021.
incident reporting systems are widely utilised within healthcare to analyse adverse events and have been shown to reduce patient harm. With data to suggest high anaesthetic-related mortality in low and middle-income countries (LMICs), such systems could allow more accurate determination of rates and types of incidents and could improve patient safety.
this prospective observational study carried out over six-weeks in March to April 2019 in an Ethiopian tertiary referral hospital, included direct observations in the operating room and recording of any anaesthesia-related adverse events occurring during the perioperative period.
fifty surgical cases were observed during weekday daytime hours. Sixteen anaesthesia-related adverse events were observed in 12 patients, including six elective cases and six emergencies, an adverse event rate of 32% (n=16), affecting 24% (n=12) of patients. Most incidents occurred in infants less than one-year-old and those between 11-20 years (31.3%; n=5 each) and those undergoing general anaesthesia (66.7%; n=8), particularly during the induction phase (50%; n=8), the most common event being prolonged desaturation (31.3%; n=5). Most events were considered to contribute a low level of harm (56.3%; n=9). There were no intra-operative mortalities.
this study presents evidence of a higher rate of adverse events during anaesthesia at a tertiary referral hospital in Ethiopia, than reported in current literature from LMICs. There is potential for large volume data to be produced and learnt from with a reporting system in place in this setting. The most common event was desaturation detected by pulse oximetry, particularly in paediatric surgery.
事故报告系统在医疗保健领域被广泛应用于分析不良事件，并已被证明可减少患者伤害。由于数据表明中低收入国家（LMICs）的麻醉相关死亡率较高，因此此类系统可以更准确地确定事件的发生率和类型，并提高患者安全性。
本前瞻性观察研究于 2019 年 3 月至 4 月在埃塞俄比亚一家三级转诊医院进行，为期六周，包括对手术室的直接观察以及记录围手术期发生的任何与麻醉相关的不良事件。
在工作日白天观察了 50 例外科手术。在 12 名患者中观察到 16 例与麻醉相关的不良事件，包括 6 例择期手术和 6 例紧急手术，不良事件发生率为 32%（n=16），影响了 24%（n=12）的患者。大多数事件发生在一岁以下的婴儿和 11-20 岁的儿童中（31.3%；n=5 例）以及接受全身麻醉的患者中（66.7%；n=8 例），特别是在诱导阶段（50%；n=8 例），最常见的事件是长时间的血氧饱和度下降（31.3%；n=5 例）。大多数事件被认为造成的伤害程度较低（56.3%；n=9 例）。术中无死亡。
本研究在埃塞俄比亚的一家三级转诊医院报告了麻醉期间不良事件发生率高于当前来自 LMICs 的文献报告，表明该医院有大量数据可供学习。在这种情况下，建立报告系统可能会产生大量数据并从中学习。最常见的事件是脉搏血氧饱和度监测到的血氧饱和度下降，尤其是在小儿手术中。
