Critical incidents in anesthesia: increasing number through voluntary anonymous reporting, University Hospital, Honduras, 2014

Abstract

Background: The critical incidents (CI) are an important cause of perioperative morbidity and mortality. Objective: To describe the characteristics of the IC in anesthesia according to three sources, Operating Room, University College Hospital, Tegucigalpa, Honduras, May-June 2014. Methodology: A cross-sectional study of ASA I-II patients. CI was recorded according to three sources: anonymous Voluntary Communication Questionnaire (VCQ), Anesthesia Form (AF) and Nursing Book (NB). A database was created using EpiInfo Vs.7; with uni-bivariate analysis. Results: In 504 patients undergoing surgery, 40 (7.9%), 20 (4.0%) and 8 (1.6%) CI were recorded according to VCQ, AF and NB, respectively. The person responsible for CI was First-year Resident 40.0% (16) VCQ, Anesthesia Technician 41.6% (4) AF and First-year Resident 50.0% (4) NB. In VCQ, average hours worked before CI 11 hours (1-30 hours) and mean years of experience 3 (0.4-24 years). The CI occurred in the maintenance period 42.5% (17) VCQ, 58.3% (7) AF and 62.5% (5) NB. CI was mild and moderate 15.0% (6) and 75.0% (30) VCQ, 16.6% (2) and 66.6% (8) AF and 25.0% (4) and 50.0% (3) NB, respectively. The identified causes were lack of experience 37.5% (15) VCQ, 33.3% (4) AF and 25.0% (2) NB, no/inappropriate aid 27.5% (11) VCQ, central oxygen failure 7.5% (3) VCQ and 60.0% (4) NB. Discussion: Through voluntary anonymous communication, CI increased 2 to 5 times compared to those reported in AF and NB, respectively. It is recommended the establishment of an adequate registration system for CI and supervision and training for less experienced staff.