Accidents, near accidents and complications during anaesthesia A retrospective analysis of a 10‐year period in a teaching hospital

Chopra, V.; Bovill, J. G.; Spierdijk, J.

doi:10.1111/j.1365-2044.1990.tb14492.x

Cited by 130 publications

(78 citation statements)

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“…[35][36][37][38][39][40][41][42] This partly reflects the role of actual equipment failure, reported to occur in 15-20% of the procedures, but probably also refers to overall quality of care.…”

Section: Discussionmentioning

confidence: 99%

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

et al. 2005

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This article and its accompanying editorial have been selected for the Anesthesiology CME Program. After reading both articles, go to http://www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue.Background: Quantitative estimates of how anesthesia management impacts perioperative morbidity and mortality are limited. The authors performed a study to identify risk factors related to anesthesia management for 24-h postoperative severe morbidity and mortality.Methods: A case-control study was performed of all patients undergoing anesthesia (1995-1997). Cases were patients who either remained comatose or died during or within 24 h of undergoing anesthesia. Controls were patients who neither remained comatose nor died during or within 24 hours of undergoing anesthesia. Data were collected by means of a questionnaire, the anesthesia and recovery form. Odds ratios were calculated for risk factors, adjusted for confounders.Results: The cohort comprised 869,483 patients; 807 cases and 883 controls were analyzed. The incidence of 24-h postoperative death was 8.8 (95% confidence interval, 8.2-9.5) per 10,000 anesthetics. The incidence of coma was 0.5 (95% confi-

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Section: Discussionmentioning

confidence: 99%

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

et al. 2005

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“…1 The reported frequency of intraoperative cardiac arrest varies widely, from 2.56 to 39 cases per 10,000 operations. [1][2][3][4][5][6] However, it is difficult to assess the quality of cardiopulmonary resuscitation (CPR) because of an absence of standardized templates for describing resuscitation efforts and for classifying the intraoperative complexity of such cases. Furthermore, limited data are available regarding the predictors of CPA survival and 30-day clinical outcomes.…”

Section: Introductionmentioning

confidence: 99%

Frequency of intraoperative cardiac arrest and medium-term survival

et al. 2013

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CONTEXT AND OBJECTIVE: Although advances in surgical and anesthetic techniques have reduced perioperative morbidity-mortality, the survival rate following cardiac arrest remains low. The aim of this study was to evaluate, over the course of one year, the prevalence of intraoperative cardiac arrest and the 30-day survival rate after this event in a tertiary teaching hospital. DESIGN AND SETTING: Prospective cohort study in a tertiary teaching hospital. METHODS: Following approval by the institutional ethics committee, anesthetic procedures and cases of intraoperative cardiac arrest between January and December 2007 were evaluated. Patients undergoing cardiac surgery were excluded. The data were gathered prospectively using the modified Utstein model, with evaluation of demographic data, pre-arrest conditions, intraoperative care, care during arrest and postoperative outcome up to the 30 th day. The data were recorded by the attending anesthesiologist. RESULTS: During the study period, 40,379 anesthetic procedures were performed, and 52 cases of intraoperative cardiac arrest occurred (frequency of 13:10,000). Among these, 69% presented spontaneous return of circulation after the initial arrest, and only 25% survived for 30 days after the event. The following factors were associated with shorter survival: American Society of Anesthesiologists physical status IV and V, emergency surgery, hemorrhagic events, hypovolemia as the cause of arrest and use of atropine during resuscitation. CONCLUSIONS: Although the frequency of cardiac arrest in the surgical environment has declined and resources to attend to this exist, the survival rate is low. Factors associated with worst prognosis are more frequent in critical patients. RESUMOCONTEXTO E OBJETIVO: Apesar de avanços nas técnicas cirúrgicas e anestésicas terem reduzido a morbimortalidade perioperatória, a taxa de sobrevivência após parada cardíaca (PC) permanece baixa. O objetivo deste estudo foi avaliar, ao longo de um ano, a incidência de PC intraoperatória e de sobrevida por 30 dias após esse evento em um hospital terciário de ensino.

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“…Published studies on drug errors in anesthesia have not classified the type of drug errors, 5 been small in numbers, or based on voluntary anonymous incident reports. [6][7][8] This latter method of study has been shown to capture only a small fraction of adverse drug events. [9][10][11] Thus, the real magnitude, or incidence, of drug errors in anesthesia practice is not known.…”

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confidence: 99%

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Fasting

Gisvold

2000

Can J Anesth/J Can Anesth

158

149

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Purpose: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. Methods:We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity.Results: A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04).Conclusion: Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.Objectif: Décrire les erreurs de médicaments en anesthésie clinique selon leur fréquence et leur nature et éva-luer si une modification de la couleur des étiquettes codées des seringues pouvait, avec une certaine formation, résoudre ce problème. Conclusion : Les erreurs de médicaments sont rares et ne représentent qu'une petite partie des problèmes anesthésiques, mais elles sont toujours potentiellement dangereuses. Les échanges de seringues surviennent le plus souvent entre seringues de même taille et ils ne sont pas réduits par les étiquettes de couleurs codées. Les myorelaxants, le plus souvent en cause, peuvent entraîner une morbidité résiduelle. Des mesures préventives spéciales devaient être envisagées dans ce cas.

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Accidents, near accidents and complications during anaesthesia A retrospective analysis of a 10‐year period in a teaching hospital

Cited by 130 publications

References 9 publications

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality

Frequency of intraoperative cardiac arrest and medium-term survival

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

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