An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006-2008

Abstract

Objectives/aims: We aimed to identify and analyze critical incidents relating to pediatric anesthesia from the National Reporting and Learning System (NRLS) in England and Wales.

Background: Critical incident reporting plays a key role in learning from problems and so enhancing patient safety. There has been no previous analysis of pediatric anesthetic incidents in the NRLS.

Methods: We obtained potentially relevant records from the UK National Patient Safety Agency. Eligible incidents were classified according to patient age, degree of harm sustained, and clinical category.

Results: A total of 606 incidents met the inclusion criteria. Six deaths were reported and 48 incidents resulted in severe harm. In many reports, sufficient detail was lacking for a full understanding of what had happened. However, the broad focus of the NRLS revealed a wide spectrum of clinical and organizational incidents relating to pediatric anesthesia. Medication issues predominated (35.6%), notably inadvertent duplication of dosing in operating theater and ward. Airway/ventilation incidents formed 18.8% of the total, cardiovascular incidents 5.9%, and equipment-related incidents (failure or unavailability) 15.7%. Communication and organizational problems made up 8.6% of reports.

Conclusions: We make a number of recommendations for practice. In addition, anesthetists should be encouraged to take ownership and contribute high-quality descriptions of incidents to national systems.