Adverse events in anaesthetic practice
Editor—I read with interest the article by Smith and colleagues1 on adverse events in anaesthetic practice. I have recently completed an audit in our anaesthetic department to ascertain the reason why critical incidents are under-reported. My audit relied on both consultants and registrars completing an anonymous questionnaire, the results of which are summarized in Table 1. I was pleasantly surprised to see that we are overcoming the era of ‘blame culture’ and that triviality was the most common reason for under-reporting. I, as do some of my colleagues anaesthetists, agree that the definition of ‘criticality’ is ambiguous. As a result most of us would not regard situations such as laryngospasm and circuit disconnection as a ‘critical’ incident. Anaesthesia as a speciality is fraught with life-threatening situations that are not necessarily unexpected. If these situations are treated promptly and appropriately without consequence, are they truly ‘critical’ incidents? However, I feel that unusual events or situations where a lesson can be learnt should be reported as they are an essential learning tool that without a doubt contributes to patient safety.
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E-mail: kar_wouters{at}yahoo.com
References
1 Smith AF, Goodwin D, Mort M, Pope C. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Br J Anaesth 2006; 96:715–21
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