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ANALYSIS OF CRITICAL

INCIDENTS IN PEDIATRIC
ANAESTHESIA - A
CLINICAL STUDY

Atvionita Sinaga
112015398
ABSTRACT:
Background:
Critical incident monitoring is important in
quality improvement and patient safety as it
identifies potential risks to patients by analyzing
adverse events
The present study was conducted to report the
incidence of critical events occurring in the
department of anesthesia during surgery in
children.
ABSTRACT:
Materials & Methods:
This study was conducted in the department of
anesthesia in Jan 2015 to Dec 2015. It included
1050 children up to 15 years of age who
underwent any procedure in pediatric surgery
INTRODUCTION
The original definition of a critical incident by
Cooper and colleagues was an occurrence that
could have led or did lead to an undesirable
outcome.
There are many established incident monitoring
programs worldwide in anesthesia including the -
-American Society of Anesthesiologists (ASA)
- Committee on Patient Safety and Risk
Management,
- National Patient Safety Agency in the United
Kingdom.
INTRODUCTION
Reporting of critical incidents and near misses is an
established method of improving patient safety.
Most countries adopt a National Reporting system for
identifying critical incidents,
- Australian Incident Monitoring System (AIMS),
- National Reporting and Learning Systems (NRLS).
United Kingdom (UK)
INTRODUCTION
The present study was conducted to report the
incidence of critical events occurring in the
department of anesthesia during surgery in
children.
MATERIALS & METHODS
This study was conducted in the department of
anesthesia in Jan 2015 to Dec 2015. It included
1050 children upto 15 years of age who
underwent any procedure in pediatric surgery
MATERIALS & METHODS
Inclusion:
Children undergoing Cardiac and ear, nose, throat
(ENT) surgeries, thoracic, abdominal, genitourinary
procedures, neurosurgeries and paediatric surgeries
such as circumcision,lymph node biopsy.
MATERIALS & METHODS
Exclusion:
Children having pre-operative cardiovascular
compromise (hypotension, hypertension, arrhythmias)
were excluded from cardiovascular adverse events.
Those having pre.operative desaturation/hypercarbia
(congenital diaphragmatic hernia [CDH],
tracheoesophageal fistula) were excluded from
respiratory adverse events.
RESULTS
Table I Distribution of patients

Neonates Infants Toddlers Other children


250 300 340 160
Total 1050
RESULTS

Table II Incidence of critical events in patients


Total Incidence
Neonates 250 25 (10%)
Infants 300 33 (11%)
Toldders 340 44 (13%)
Other Childen 160 24 (19%)
Total 1050 126 (12%)
RESULTS
Graph I Distribution of respiratory and airway critical incidents
RESULTS

Graph II Cardiovascular incidents


RESULTS
Graph III Degree of patient harm
RESULTS
Graph IV Critical incidents and duration of surgery
DISCUSSION
Critical incidents may be useful in assessing the
complications that can occur following
anaesthesia.
Critical incident analysis was first introduced by
Flanagan in 1954 and was used in aviation.
The present study was conducted to report the
incidence of critical events occurring in the
department of anesthesia during surgery
DISCUSSION
In year 2015, 1050 children patients underwent
surgery due to several reasons. 250 were
neonates, 300 were infants, 340 were toddlers
and 160 were other children.
In this study, we found that 25 neonates, 33
infants, 44 toddlers and 24 other children had
critical events. The incidence rate was 12%.
DISCUSSION
We found that maximum cases of incidents were
of respiratory incidents such as laryngospasm
followed by Supraglottic airway device (SGD)
related incidents, accidental extubation, upper
airway obstruction, bronchospasm
Degree of harm recorded maximum cases of
moderate harm in her study.
DISCUSSION
We found that Graph IV shows that critical
incidents occurred in less than 2 hours (68), 2-6
hours (44) and more than 6 hours (14) surgeries.
Khan FA11 suggested that shorter the procedure
more likely to happen the incidents.
DISCUSSION
Critical incident reporting is avaluable part of
quality assurance. Identifying and mitigating
risk factors associated with patient harm can
improve patient safety.
Higher ASA status appears to be the most
important contributory factor that results in
actual or potential patient harm in our study
CONCLUSION
Critical incident reporting is useful in
perioperative safety of children. The
anaesthesiologists can play important role in
recording critical incidents. There is need to
established critical incident monitoring system.

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