Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country

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Abstract

Background and Aims:

The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice.

Material and Methods:

Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed.

Results:

A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases.

Conclusion:

Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

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Most cited references 14

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Critical incident reporting and learning.

R P Mahajan (2010)

The success of incident reporting in improving safety, although obvious in aviation and other high-risk industries, is yet to be seen in health-care systems. An incident reporting system which would improve patient safety would allow front-end clinicians to have easy access for reporting an incident with an understanding that their report will be handled in a non-punitive manner, and that it will lead to enhanced learning regarding the causation of the incident and systemic changes which will prevent it from recurring. At present, significant problems remain with local and national incident reporting systems. These include fear of punitive action, poor safety culture in an organization, lack of understanding among clinicians about what should be reported, lack of awareness of how the reported incidents will be analysed, and how will the reports ultimately lead to changes which will improve patient safety. In particular, lack of systematic analysis of the reports and feedback directly to the clinicians are seen as major barriers to clinical engagement. In this review, robust systematic methodology of analysing incidents is discussed. This methodology is based on human factors model, and the learning paradigm which emphasizes significant shift from traditional judicial approach to understanding how 'latent errors' may play a role in a chain of events which can set up an 'active error' to occur. Feedback directly to the clinicians is extremely important for keeping them 'in the loop' for their continued engagement, and it should target different levels of analyses. In addition to high-level information on the types of incidents, the feedback should incorporate results of the analyses of active and latent factors. Finally, it should inform what actions, and at what level/stage, have been taken in response to the reported incidents. For this, local and national systems will be required to work in close cooperation, so that the lessons can be learnt and actions taken within an organization, and across organizations. In the UK, a recently introduced speciality-specific incident reporting system for anaesthesia aims to incorporate the elements of successful reporting system, as presented in this review, to achieve enhanced clinical engagement and improved patient safety.

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A comparison of pediatric and adult anesthesia closed malpractice claims.

Frederick Cheney, Jeremy M. Geiduschek, J P Morray … (1993)

Since 1985, the Committee on Professional Liability of the American Society of Anesthesiologists has evaluated closed anesthesia malpractice claims. This study compared pediatric and adult closed claims with respect to the mechanisms of injury, outcome, the costs, and the role of care judged to be substandard. Using a standardized form and method developed for analysis of closed claims, the American Society of Anesthesiologists Closed Claims Data Base was used to compare pediatric with adult anesthesia-related adverse events. Of the 2,400 total claims, 238 (10%) were in the pediatric age group (15 yr of age or younger). The pediatric claims presented a different distribution of damaging events compared with that of adults. In particular, respiratory events were more common among pediatric claims (43% versus 30% in adult claims; P < or = 0.01). The mortality rate was greater in the pediatric claims (50% versus 35% in adult claims; P < or = 0.01), anesthetic care more often was judged less than appropriate (54% versus 44% in adult claims; P < or = 0.01), the complications more frequently were thought to be preventable with better monitoring (45% versus 30% in adult claims; P < or = 0.01), and the distribution of payments to the plaintiff was different (median payment, $111,234 versus $90,000 in adult claims; P < or = 0.05). Many of the differences between pediatric and adult claims were explained by a higher prevalence of patient injury caused by inadequate ventilation in the pediatric claims (20% versus 9% in adult claims; P < or = 0.01). In pediatric compared with adult inadequate ventilation claims, poor medical condition and/or obesity (6% versus 41%; P < or = 0.01) were uncommon associated factors. Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation, resulting in death (70%) or brain damage (30%) in previously healthy children. Although clinical clues suggested hypoxemia as a common mechanism of injury, the files did not contain enough information to explain the genesis of hypoxemia in these claims. Comparison of adult and pediatric closed claims revealed a large prevalence of respiratory related damaging events--most frequently related to inadequate ventilation. In the opinion of the reviewers, 89% of the pediatric claims related to inadequate ventilation could have been prevented with pulse oximetry and/or end tidal CO2 measurement. However, pulse oximetry appeared to prevent poor outcome in only one of seven claims in which pulse oximetry was used and could possibly have done so.

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Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore.

Samuel Tay, S Ng, K. Tan (2001)

We undertook an audit of paediatric perioperative incidents in the first 10000 anaesthetics administered in KK Women's and Children's Hospital in Singapore between May 1997 and April 1999. The spectrum of surgery performed ranged from simple ambulatory surgery to open heart surgery for complicated congenital heart diseases. An audit form is completed for every anaesthetic delivered and critical incidents are reported on the reverse blank page of the audit form. An anaesthetic incident was defined as 'any incident which affected, or could have affected, the safety of the patient under anaesthetic care'. Two hundred and ninety-seven critical incidents were reported. The majority of them happened in healthy patients (80.1% ASA I and II) scheduled for elective surgery (73.3%). Critical incidents in infants less than 1 year of age were four times as common as in older children (8.6% versus 2.1%). Incidents occurred mainly during maintenance (80.6%). There was no anaesthetic mortality. Respiratory events were the most common (77.4%) with laryngospasm accounting for 35.7%. Cardiovascular incidents (10.8%) included hypotension from haemorrhage and sepsis, and dysrhythmias. The incidence of equipment and pharmacologically related problems was low. Future reviews of a larger patient population may be helpful to determine trends of perioperative events and whether quality assurance programs have made a difference.

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Author and article information

Journal

Journal ID (nlm-ta): J Anaesthesiol Clin Pharmacol

Journal ID (iso-abbrev): J Anaesthesiol Clin Pharmacol

Journal ID (publisher-id): JOACP

Title: Journal of Anaesthesiology, Clinical Pharmacology

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 0970-9185

ISSN (Electronic): 2231-2730

Publication date (Print): Jan-Mar 2018

Volume: 34

Issue: 1

Pages: 78-83

Affiliations

[1]Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan

Author notes

Address for correspondence: Dr. Shemila Abbasi, Aga Khan University Hospital, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan shemila.abbasi@ 123456aku.edu

Article

Publisher ID: JOACP-34-78

DOI: 10.4103/joacp.JOACP_240_16

PMC ID: 5885455

SO-VID: fcf8ab85-942a-46f1-9451-e5d5cf352d7e

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country

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Abstract

Background and Aims:

Material and Methods:

Results:

Conclusion:

Related collections

Pediatric Pulse: Advancing Neonatal and Child Health

Most cited references 14

Critical incident reporting and learning.

A comparison of pediatric and adult anesthesia closed malpractice claims.

Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore.

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