TITLE:
Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning
AUTHORS:
Mohammad Hamid, Mohammad Irfan Akhtar, Fauzia Nasim Minai, Amar Lal Gangwani
KEYWORDS:
Paediatric; Congenital Heart Surgery; Anaesthesia; Errors
JOURNAL NAME:
Open Journal of Anesthesiology,
Vol.3 No.9,
November
21,
2013
ABSTRACT: Incident reporting is a
reliable quality assurance tool, frequently used in anaesthesia to identify
errors. It was introduced in anaesthesia by Cooper in 1978 and since then
several institutions have adopted this system to find adverse events and near
misses. We think that the incident reporting would be more beneficial for
prolonged and technically complex procedures like paediatric cardiac surgery. Methods: All
paediatric CHD patients scheduled for cardiac surgery were included in this
audit. Thoracic and general surgery patients were excluded. Any event in
preoperative area, induction room, operating room and during transfer to
cardiac ICU was documented in a predesigned proforma by resident/consultant. This proforma included
information regarding demographics, the type and severity and responsible
factors for the event. Results: 134 patients were included in this two and half years audit. 88 patients
were male (65.7%) and 46 (34.3%) were female. The age of the patients ranged
from one day to 15 years. Total 105 incidents were noticed in 61 patients. 46
incidents were declared as major events which were potentially serious while 59
events were of minor nature. Cuffed endotracheal tube was used in 73% patients.
The majority of events occurred in the pre-bypass period. Most of the incidents
were related to cardiovascular system (73%), followed by pharmacological
incidents. Human factors (74%) were mainly responsible for the incidents. Conclusion: Incident reporting is a reliable and
feasible method of improving quality care in developing countries. It helps in
identifying areas which need improvement and helps in developing guidelines to
improve safety.