Systems analysis of voluntary reported anaesthetic safety incidents occurring in a university teaching hospital

• Published in: Veterinary anaesthesia and analgesia Vol. 45; no. 1; pp. 3 - 12
• Main Authors: McMillan, Matthew W., Lehnus, Kristina S.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Ltd 01.01.2018
• Subjects: anaesthesia; Anesthesia - adverse effects; Anesthesia - standards; Anesthesia - statistics & numerical data; Animals; Hospitals, Animal - standards; Hospitals, Animal - statistics & numerical data; Hospitals, Teaching - standards; Hospitals, Teaching - statistics & numerical data; Hospitals, University - standards; Hospitals, University - statistics & numerical data; human factors; incidents; Medical Errors - statistics & numerical data; patient safety; Prospective Studies; Risk Management - statistics & numerical data; Systems Analysis; incidents; patient safety; human factors; systems analysis; anaesthesia
• ISSN: 1467-2987; 1467-2995
• DOI: 10.1016/j.vaa.2017.06.007

To identify factors contributing to the development of anaesthetic safety incidents. Prospective, descriptive, voluntary reporting audit of safety incidents with subsequent systems analysis. All animals anaesthetized in a multispecies veterinary teaching hospital from November 2014 to October 2016. Peri-anaesthetic incidents that risked or caused unnecessary harm to an animal were reported by anaesthetists alongside animal morbidity and mortality data. A modified systems analysis framework was used to identify contributing factors from the following categories: Animal and Owner, Task and Technology, Individual, Team, Work Environmental, and Organizational and Management. The outcome was graded using a simple descriptive scale. Data were analysed using Pearson's Chi-Square test for association and univariable and multivariable logistic regression analysis. Totally, 3379 anaesthetics were performed during the audit period. Of these, 174 incident reports were analysed, 163 of which impacted safe veterinary care and 26 incidents were considered to have had major or catastrophic outcomes. Incident outcome was believed to have been limited by anaesthetist intervention in 104 (63.8%) cases. Various factors were identified as: Individual in 123 (70.7%), Team in 108 (62.1%), Organizational and Management in 94 (54.0%), Task and Technology in 80 (46.0%), Work Environmental in 53 (30.5%) and Animal and Owner in 36 (20.7%) incidents. Individual factors were rarely seen in isolation. Significant associations were identified between Experience and Supervision, X2 (1, n=174)=54177, p=0.001, Failure to follow a standard operating procedure and Task Management, X2 (2, n=174)=11318, p=0.001, and Staffing and Poor Scheduling, X2 (1, n=174)=36742, p=0.001. Animal Condition [odds ratio (OR)=16210, 95% confidence interval (CI)=5573–47147)] and anaesthetist Decision Making (OR=3437, 95% CI=1184–9974) were risk factors for catastrophic and major outcomes. Individual factors contribute to many safety incidents but tend to occur concurrently with other factors. Anaesthetist intervention limits the consequences of incidents for most animals.