| Popis: |
Background Safe anesthesia practice is by default the ultimate target for every anesthesiologist. Mortality and morbidity discussions constitute the most important method to address this issue, although a well-designed productive mortality and morbidity discussion is rare. In this study we tried to initiate a project of a systematic mortality and morbidity analysis that could easily gather data about the incident. These data were statistically analyzable and could finally address the problem. Materials and Methods A total of 56 mortality and morbidity reports from July 2009 to August 2012 were reviewed. These were analyzed using a self-constructed chart. This chart was designed to achieve the goal of addressing the problem. This chart also assessed the degree of attribution of the incident to anesthesia, anticipation of the incidents, and the contributing factors that led to this incident. Results Equal distribution of the three main categories of contributing factors (preoperative, intraoperative, and postoperative) was noticed, although 62% of the incidents could be easily gathered under a specific scenario of inappropriate preoperative management (20%) that led to improper choice of anesthesia (22%). Logically, this will lead to poor anticipation of intraoperative complications, followed by poor crisis management (14%) and finally insufficient postoperative management (6%). Hence, poor planning was responsible for 62% of the incidents. This result was supported by an almost similar percentage (65%) of unanticipated incidents. Moreover, 8% of the errors analyzed comprised system errors, which is a relatively high percentage. Conclusion Poor planning and nonanticipation of complications are the major problems that should be overcome by improving anesthesia planning. Also a stronger system is needed to minimize system errors. |
