1. Anaesthetic Event Database Report April 2007 R. Marcus Birmingham Children’s Hospital

2. Incident reporting at BCH  1569 reports from 5 years  Databased and Categorised –Classification –Subclassification –Anaesthetic human factors  Nomenclature developed from reports and previous publications  715 human factors in 674 reports –43% of incidents reported

3. Event classification totalpreventable Airway/Respiratory70854.8% CVS23517.9% Equipment21772.4% Organization9993.9% Other4957.1% Pharmacology9762.9% Procedure8843.2%

4. Immediate outcomes

5. Predicted long term outcomes

6. Human factors pie chart

7. Errors of Judgement 303 (42.4%) Inadequate depth of anaesthesia 119 (16.6%) Trachea extubated at wrong time 61 (8.5%) Anaesthetizing child with URTI 59 (8.3%) Other error of judgment 33 (4.6%) Inadvisable anaesthetic technique 31 (4.3%)

8. Failure to Check 105 (14.2%) Equipment 46 (6.4%) Tracheal tube 28 (3.9%) Intravenous/arterial line 23 (3.2%) Drug/other 8 (1.1%)

9. Failures of Skills 72 (10.1%) Central venous access 27 (3.8%) Airway 17 (2.4%) Local Block/Epidural 14 (2%) Intravenous/arterial line 14 (2%)

10. Lack of care 65 (9.1%) Inexperience (may be of attached trainee) 51 (7.1%) Inattention 31 (4.3%) Poor pre-operative preparation/assessment 31 (4.3%) Communication 25 (3.5%) Teaching 15 (2.1%) Drug dosage slip 12 (1.7%) Other 10 (1.4%) Pressure to do case 2 (0.3%)

11. The 6 most common causative factors in this study and the AIMS study For ease of comparison the fault of technique category (13%) in the AIMS study has been included in the errors of judgment to match the classification used in this study. THIS STUDYAIMS STUDY CAUSATIVE FACTOR% of incidents CAUSATIVE FACTOR% of incidents Error of judgment42.4%Error of judgment*29% Failure to check14.2%Failure to check equipment 13% Technical failure of skill10.1%Others13% Lack of care9.1%Inattention12% Inexperience7.1%Haste12% Inattention4.3%Inexperience11%

12. Yearly incidents reported by each Consultant

13. Overall incident types

14. Example of Generalist

15. Example of Cardiac Anaesthetist

16. Example of someone who reports many Problems with organization/equipment

17. Overall human factors

18. Individual 1

19. Individual 2

20. Individual 3

21. Individual 4

22. Reporting rates vary  Median 10 (IQR 6.6-15) a year  Range 0.2 to 35 per year  What is acceptable range? –Too many  is that anaesthetist unsafe?  or do they under report less? –Everyone under reports! –Too few  are they super-safe?  or just avoiding reporting? –And hence a risk!  Voluntary reporting

23. Different patterns of reporting  We are variable –Caseload  Cardiac  Livers  Neuro –Bees in our bonnets over certain issues  Portex LMAs  Communication  Organization –NO definite list of triggers for a report

24. Patterns of human error  Patterns do vary between individuals –How valid are comparisons?  Reporting habits vary  Still after 5 years small numbers for most individual so percentages can be misleading  Overall reporting rates vary, so plain numbers can be misleading also –All interpretation of incidents are by me, so may be wrong

25. Pros and cons of collecting data  PROS –Education of self –Education of others –Evidence for revalidation  Proof of cooperation with reporting  Learning from errors –Defence if a SUI occurs –Publication  Department profile  CONS –Could be used against you  High reporting rates  SUI  Lack of understanding by others –Trial by press?  May be disclosable under FOI act  Trust may not release individuals data on a whim

26. ISSUES & QUESTIONS  Missed some people’s data due to changeover to electronic version  Has been retrospective (3+ months or so), will become more up to date with electronic system  My interpretation…open to question  Is it useful in its mechanisms of feedback?

27. CONCLUSIONS –Confidential? Voluntary –Variable reporting rates –Interpretation by me as to factors –Feedback of overall and individual data –Do act on issues that are raised –Pumps –LMAs –Drug errors –How do we ensure that it cannot be misinterpreted by those outside anaesthesia?