Improvements in anaesthetic care resulting from a critical incident reporting programme

摘要: The role of an anaesthetic incident reporting programme in improving safety was studied. had been running for 4 to 5 years three large hospitals Hong Kong and more than 1000 incidents have reported. number reports being made frequency the various categories reported, did not alter during study period. Sixty nine percent were considered be preventable. Human error contributed 76% violations standard practice 30% incidents. effective its ability detect latent errors anaesthesia system when these corrected, recur. with which contributing factors cited decrease time. With exception problems dealt by specific protocol development, found no evidence that increasing awareness problem human reducing this kind problem.