PATIENT AWARENESS DURING ANESTHESIA - AN ANALYSIS OF 2000 INCIDENT REPORTS

Amongst the first 2000 incidents reported to the Australian Incident M onitoring Study there were 16 cases in which patient recall of periope rative events was consistent with awareness. Awareness that occurred i n 3 of 10 cases during anaesthesia was attributed to low concentration s of volatile anaesthetic agent; the conduct of anaesthesia appeared t o be unremarkable in the other 7. The remaining 6 cases involved the i nadvertent paralysis of patients prior to induction of anaesthesia, mo st commonly by ''syringe swap'' when suxamethonium was given instead o f fentanyl. Some of these patients were significantly distressed. Thes e preliminary findings suggest that incident monitoring should be usef ul in the study of awareness associated with anaesthesia and the devel opment of strategies to prevent it.