Ten years of pediatric critical incidents reported in the Spanish anesthesia safety notification system and resuscitation

Abstract

Objetives: The aim of this study is to analyze all the pediatric critical incidents (PCI) reported in the Spanish Anesthesiology and Reanimation Safety Notification System in ten years time. Materials and Methods: We reviewed all the critical incidents (CI) reported between the years 2009 and 2018 in SENSAR online database and we selected those related to newborns and children up to 16 years. Results: 9480 CI were declared; 474 were pediatrics. Infants accounted for the 36% of the PCI, of whom the 44% were children under the age of one. Most of them affected to healthy patients (the 66%) and took place in the operating room (the 49%), during general pediatric surgery (the 19%), otorhinolaryngology (the 15%), orthopedic (the 13%) and radiology procedures (the 5%). The majority of them were medications errors (the 24%), followed by clinical incidents (the 18%) and equipment-related events (14%). Human factor accounted for the 42% of reports - both of them in its individual characteristics (the 25%) and in team performance (the 15%). Up to the 30% of the children suffered consequences derived from the incidents. Two fatal events were recorded, both airway related. Improvement measures were designed and implemented in the 93% of them. Conclusions: Designing studies that shed light on the causes of the relative inefficiency of CI Reporting Systems and the factors that condition a lower rate of CI communication in the pediatric setting in comparison with the adult population is necessary.