Critical incident monitoring in anaesthesia

摘要: Critical incident monitoring in anaesthesia is an important tool for quality improvement and maintenance of high safety standards anaesthetic services. It now widely accepted as a useful technique reducing morbidity mortality has become part the many assurance programmes general hospitals under Ministry Health. Despite wide-spread reservations about its value, critical classical qualitative research which particularly where problems are complex, contextual influenced by interaction physical, psychological social factors. Thus, it well suited to be used probing complex factors behind human error system failure. Human significant contributions morbidities mortalities anaesthesia. Understanding relationships between, errors, incidents accidents prevention risk management reduce harm patients. Cardiac arrests operating theatre (OT) prolonged stay recovery, constituted bulk reported incidents. OT resulted involved mostly de-compensated patients those with unstable cardiovascular functions, presenting emergency operations. Prolonged-stay recovery extended period observation ill Prolonged was justifiable some cases, these needed longer post-operative until they were stable enough return ward. The advantages relatively low cost, ability provide comprehensive body detailed information, can develop strategies prevent manage existing plan further initiatives patient makes valuable ensuring safety. contribution reporting issue far from clear very difficult study. Efforts do so have tended rely on reporting, only practical approach when funding limited. heterogeneity critically group means that huge study populations would required if other techniques used. In era evidence-based medicine, anaesthetists looking alternative solutions we traditionally cannot quantify good reasons. quest safety, investment should made reliable audit, detection systems. growing recognition usually result failure rather than individual fostered allow more lessons learnt, been successful other, safety-critical industries. New technology great deal offer warranted novel fail-safe drug administration Last but not least importance simple sensible changes better education remembered.