Complaints related to respiratory events in anaesthesia and intensive caremedicine from 1994 to 1998 in Denmark

Background: In Denmark, a National Board of Patients' Complaints (NBPC) was founded in 1988. This study analyses anaesthetic complaints related to adv erse respiratory events filed at the NBPC from 1994 to 1998 to point out di rections for possible preventive measures. Methods: All decisions made by the NBPC from 1994 to 1998 concerning person nel employed in the Danish health care system were scrutinized. Cases relat ed to anaesthesia and intensive care medicine were reviewed. Adverse respir atory events were identified and classified by mechanism of the incident th at had caused the complaint. Detailed information on anaesthetic technique, personnel involved, sequence of events, clinical manifestation of injury, and outcome was recorded. Results: A total of 284 cases was identified. One-fifth (n = 60) of the com plaints were related to an adverse respiratory event. The overall mortality in these cases was 50% (n = 30). In 19 complaints (32%), the treatment was considered substandard. Conclusion: Complaints related to respiratory events reveal that inadequate anaesthetic and intensive care medicine treatment leads to patient damage and death. Preventive strategies should be directed at the development of g uidelines for handling the difficult airway, education in the management of the difficult airway instruction in the correct use of anaesthetic equipme nt, improvement of interpersonnel communication routines, as well as implem entation of simulator training.