A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country

Critical incident monitoring has the advantage of identifying a potential r isk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing t he programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administe red and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirt y-nine per cent occurred during induction, 51% during maintenance and 10% d uring emergence. Human error was the cause in 41%, equipment error in 50% a nd system error in 8.5%. Twenty-two per cent of the incidents resulted in m inor, and 13% in major physiological disturbance. The technique has been fo und useful in identifying trends and selecting issues to be discussed in de partmental quality assurance meetings, but requires persistent motivation o f the reporting staff.