Critical Incidents in Post Anesthesia Care Unit (PACU) at a Tertiary Care Hospital: A Prospective Internal Audit

Abstract

Introduction: Emergence from anesthesia is the critical period. This early emergence period is rife with potential complications. In order to enable early detection and prompt treatment of these potential complications by the practitioner, there needs to be an effective system of detection and reporting of all adverse events occurring during the period of emergence. The purpose of this audit was to determine an accurate and comprehensive prospective analysis of all untoward critical incidents and their sequelae in a post anesthesia care unit of a tertiary care hospital over a period of 2 years. Material and Method: After approval from departmental research and ethical review committees, this prospective audit was conducted. An institutionally approved critical incident reporting form is already available in the department for reporting critical incidents. Anaesthesiologists were asked to report 24-hour-postoperative critical incidents as per their understanding in the post-anesthesia care unit. Results: During the two year study period, 84 critical incidents were reported with complete recovery. Incidence was maximum in patients with respiratory (20.7%) and cardiovascular (12.3%) involvements. Critical incidents most commonly occurred during the first hour of recovery room stay. Majority of these incidents (56.5%) were detected by bed side nursing staff. Most of the incidents occurred due to human error. In conclusion critical incidents reporting technique is useful in revealing trends, as an educational tool and as a method of quality improvement. We emphasize that strategies and protocols should be developed for increasing and updating knowledge to avoid errors of judgment.