IMPROVEMENTS IN ANESTHETIC CARE RESULTING FROM A CRITICAL INCIDENT REPORTING PROGRAM

The role of an anaesthetic incident reporting programme in improving a naesthetic safety was studied. The programme had been running for 4 to 5 years in three large hospitals in Hong Kong and more than 1000 inci dents have been reported. The number of reports being made and freguen cy of the various categories of incident reported, did not alter durin g the study period. Sixty nine percent of incidents were considered to be preventable. Human error contributed to 76% of incidents and viola tions of standard practice to 30% of incidents. The programme was effe ctive in its ability to detect latent errors in the anaesthesia system and then these were corrected, incidents did not recur. The frequency with which various contributing factors were cited did not decrease w ith time. With the exception of problems dealt with by specific protoc ol development, the study found no evidence that an increasing awarene ss of the problem of human error was effective in reducing this kind o f problem.