Editorial Views

EDITORIAL VIEW – Role of critical incident monitoring in anesthesia risk reduction

Fauzia A Khan*

*Tajdin H Jaffer Professor

Department of Anesthesiology, The Aga Khan University, Karachi (Pakistan)

Correspondence: Department of Anesthesiology, The Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800 (Pakistan); E-mail: fauzia.khan@aku.edu

Safety in anesthesia practice is an ongoing challenge for all practicing anesthesiologists. During anesthesia things can go wrong within seconds and these adverse events may or may not be predictable beforehand. One of the tools available to the anesthesiologists to study such events is the critical incident monitoring (CIM). A critical incident (CI) is defined as any untoward and preventable mishap which is associated with the administration of general or regional anesthesia, which led to or could have led to an undesirable patient outcome1.

CIM was first introduced by Flanagan in aviation psychology programs of the United States army in 1941 and was modified by Cooper in 1975 for application in anesthesia2. This specialty was hence a pioneer in adopting the concept of CIM in medicine. Identification of these errors is essential so that changes can be brought about in practice, both by individuals as well as departments.

CIM, as a quality improvement technique, has several advantages; it is low cost to set up and run, data collection is easy, trends become apparent, the reporting is anonymous and it acts as a biopsy of the system. In addition all aspects of anesthesia care can be monitored, e.g. preoperative, intraoperative and postoperative periods; anesthetic subspecialties, e.g. day care anesthesia, obstetrics, regional or pediatric anesthesia etc3. The technique has also been successfully applied in Critical Care to identify risk factors4. It has now gone beyond departments and some of the developed countries have national reporting systems5. Data from Australian Incident Monitoring System first showed that more than half of all anesthesia incidents were first detected by a monitor and over 90% of these could be detected by the combined use of oximetry and capnography. This was later endorsed by the World Federation of Societies of Anesthesiologists6.

The role of the technique in risk analysis has also been discussed by several authors. Risk analysis includes risk assessment, evaluation and management, in order to understand the unwanted consequences to human life, health, property and environment, as well as analytical process to provide information regarding undesirable outcomes and quantification of probabilities and consequences of identified risks7.

Analysis of CI’s identifies errors as human errors, system errors and/or equipment errors. The majority of reported incidents are due to human errors and effective strategies need to be devised to alter human behavior. Sometimes specific new protocols or structured courses in crisis management need to be introduced. More research on effectiveness of these strategies is still required8. CI analysis is particularly helpful in identifying system errors. If the system errors are beyond the control of the department they should be referred to institutional quality improvement committees.

CI program was introduced in our department in 1996. Because of this activity, several issues have been tackled and guidelines have been developed. Some of the examples are development and enforcement of guidelines on handing over of cases; intraoperative temperature monitoring, insertion and removal of pharyngeal packs, management of diabetic patients, and preoperative assessment of patients with ischemic heart disease etc.9,10. We have also looked at drug related incidents and identified and corrected system errors related to drug labeling and drug dilutions11.

In our experience we have found the activity to be a very simple and low cost quality improvement measure, which can help improve standards of patient care in developing countries. But it does require dedication, a strong belief in quality related activities and constant motivation of both consultants and trainees in the department. It can be easily replicated in other institutions with minimal costs. Eventually a national system of CIM needs to be developed. CIM is a form of continuous audit that allows diverse problems to be reported, critically analyzed and helps in putting in place strategies to tackle these problems effectively.

We suggest that all anesthesiology and intensive care departments in South Asia adopt a CIM system, specially tailored to the facilities available with them. A regular audit of the CI’s will lead us to enrich our existing knowledge and guide us towards improvement measures for the patient safety.


  1. Currie M. Anaesthesia critical events survey. Anaesthesia Intensive Care 1989;17:403- 11
  2. Cooper JB, Newbower RS, Long CD,  McPeek B. Preventable anaesthesia mishaps: a study of human factors. Anaesthesiology 1978;49(6):399-406
  3. Marcus R. Human factors in pediatric anesthesia incidents. Paediatric Anaesthesia 2006;16:242-50
  4. Buckley TA, Short TG, Rowbottom YM, Oh TE. Critical incident reporting in the intensive care unit. Anaesthesia 1997;52(5):403-9
  5. Smith AF, Mahajan RP. National critical incident reporting: improving patients safety. Br J Anaesth 2009;103(5):623-5
  6. Runciman WB. Iatrogenic harm and anaesthesia in Australia. Anaesth Intensive Care 2005;33(3):297-300
  7. Cabrini L, Lavati A. Risk management in anaesthesia. Minverva Anestesiol 2009;75(11):638-43
  8. Short TG, O’Regan A, Jayasuriya JP, Rowbottom M, Buckley TA, Oh TE. Improvements in anaesthetic care resulting from a critical incident reporting programme. Anesthesia 1996;51(7):615-21
  9. Khan FA, Hoda Q. A prospective survey of intraoperative critical incidents in a teaching hospital in a developing country. Anaesthesia 2001;56(2):171-82
  10. Khan FA, Khimani S. Customer focused incident monitoring in anaesthesia. Anaesthesia 2007;62(6):586-90
  11. Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia 2005;60(1):48-52