Anesth Pain Med.  2022 Oct;17(4):386-396. 10.17085/apm.22164.

Critical incidents associated with pediatric anesthesia: changes over 6 years at a tertiary children’s hospital

• Cho SA
• Lee JH
• Ji SH
• Jang YE
• Kim EH
• Kim HS
• Kim JT

• KMID: 2535337
• DOI: http://doi.org/10.17085/apm.22164

Abstract

Background
Sustained interest is needed in the characteristics of critical incidents in pediatric anesthesia and related changes, for determining the causes and degree of potential harm; this will also improve the quality of medical care. This study aimed to analyze the incidence of critical incidents recorded in 2014–2019, and to compare them with those in 2008–2013.
Methods
Critical incidents associated with pediatric anesthesia, including cardiac arrest, recorded in a voluntary departmental reporting system between January 2014 and December 2019 were compared with those reported between January 2008 and August 2013 using chi-square test.
Results
We identified 295 (0.55%) critical incidents from 53,541 cases of pediatric anesthesia (3,471 cardiothoracic surgeries); this is consistent with the previously reported incidence of 0.46%. Among the critical incidents, the incidences of adverse events, sentinel event, near miss case and no-harm events were 93.9%, 1.7%, 0%, and 6.1% in 2014–2019, whereas those were 98.3%, 2.6%, 1.7%, and 0% in 2008–2013 (P = 0.023, 0.686, 0.080, and < 0.001, respectively). Cardiac arrest accounted for 25 (8.5%) cases of the 295 critical events, which significantly lower than that previously reported (18.3%; P = 0.020). Human factor-related events accounted for 61.0% of all critical incidences; this was similar to the previous data (58.5%).
Conclusions
Over six years, there has been no significant difference in the total incidence of critical events. Despite the decrease in the incidence of serious critical events, perioperative care in pediatric anesthesia can be further improved.

Keyword

Anesthesia; Child; Incident reportings; Intraoperative complications; Medical errors; Perioperative care

Figure

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  Fig. 1. Critical incident reporting form (A) and central monitoring system of the operating theater in our center (B).

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  Fig. 2. The categorization of critical incidents: near miss, no-harm event, adverse event, and sentinel event.

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  Fig. 3. Detailed classification of critical incidents (A, B) and cardiac arrest (C, D) in 2014–2019 and 2008–2013. (A) Classification of total critical incidents; (B) Classification of human error-related critical incidents; (C) Classification of total cardiac arrest; (D) Classification of human error-related cardiac arrest. Data have been presented as percentages in (A) and (B), and the number of patients in (C) and (D). Data from 2008–2013 were previously published (data from the article of Lee et al. [Paediatr Anaesth 2016; 26: 409-17] [5]).

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