Composition and Risk Assessment of Perioperative Patient Safety Incidents Reported by Anesthesiologists from 2009 to 2019, a single-center retrospective cohort study

Abstract

Background: Patient safety incident reporting has been an important means of improving patient safety and enhancing organizational quality control. Reports of anesthesia-related incidents are of great value for analysis to improve perioperative patient safety. However, the utilization of incident data is far from sufficient, especially in developing countries such as China.Methods: All patient safety incidents reported by anesthesiologists in a Chinese academic hospital between September 2009 and August 2019 were collected from the incident reporting system. We reviewed the freeform text reports, supplemented them with information from the patient medical record system. Composition analysis and risk assessment were performed.Results: In total, 847 patient safety incidents were voluntarily reported by anesthesiologists during the study period among 452,974 anesthetic procedures, with a reported incidence of 0.17%, much less than the incidence reported by some developed countries. Patients with worse ASA physical status were more vulnerable to suffering from PSIs. The most common type of incident was related to the airway (N=208, 27%), followed by cardio-cerebrovascular (N=99, 13%) and pharmacological incidents (N=79, 10%). Those preventable incidents with extreme or high risk were found out through risk assessment, to provide reference for the department to implement more standard operation procedures.Conclusions: This study describes characteristics of 847 patient safety incidents voluntarily reported by anesthesiologists within eleven years in a Chinese academic hospital. Airway incidents constitute the majority of incidents reported by anesthesiologists. Under-reporting is severe in China, and the importance of summarizing and utilizing anesthesia incident data should be scrutinized.

Anesthesia-Related Airway Patient Safety Incidents Correlated with Major Adverse Cardiac Events: A Single-Center Retrospective Case-Control Analysis from 2009 to 2019

“…A patient safety incident (PSI) is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient according to the World Health Organization (WHO) classi cation for patient safety [1]. Airway incidents are the most common type of anesthesia-related PSI [2,3], and an intensive care unit (ICU) incident analysis revealed that airway incidents were more harmful for patients than other types of incidents [4]. Therefore, airway incidents have always been the top concern of anesthesiologists because this type of incident could severely threaten patient safety if not treated immediately and properly.…”