Abstract

Incidentes Críticos en Uruguay Estudio comparativo 1990-2000-2009. Anest Analg Reanim [online]. 2010, vol.23, n.2, pp.10-23. ISSN 1688-1273.

SUMMARY The analysis of collected data from the Critical Incidents survey in Uruguay is described. They are compared with the previous surveys done in 2000 and 1990. The same methodology of previous surveys was used during the 2009 Uruguayan Congress of Anesthesiology. Two different forms were used: the first one (F1) consisted of a predetermined list of critical incidents for the study of the relative frequency of each incident. The second (F2) requested the description of a particular incident chosen by the respondent. The survey was answered by 92 anesthesiologists (29% of the total of members of the Uruguayan Society of Anesthesiology). In the F1 form, 12.029 incidents were pointed out, grouped into 115 different categories. Different from previous decades, the first place of critical incidents was occupied by a new incident, the fault of monitoring devices. In F1, the respiratory origin accounted for 28% of incidents, while 20% were due to hemodynamic causes. In form F2 130 critical incidents were described, 15% of them with fatal consequences. 40% of the deaths were due only to one incident: unexpected cardiac arrest. Hemodynamic incidents had worse consequences in spite of their less percentage. In this decade there were no deaths due to esophagic intubation or nitrous oxide used as only gas. The majority of the critical incidents (different from previous decades) occurred during the intraoperative period. Acute pulmonary postobstructive edema had a clear increase. In 59% of cases the incident finding was due to clinical surveillance of the patient. Our results suggest that in spite of the technological advances, the diversity of critical incidents is maintained with a reduction of the respiratory phenomena, although these still are those most frequently found. Severity of outcomes are maintained when the incident is a hemodynamic one. With the goal of improving the results concerning patient safety, it is recommended a better evaluation both of the patient and the selected technique. In addition, checklists development and strategies for the study, prevention and correction of human error should be encouraged

Keywords : Anesthesiology; mortality; morbidity; critical incidents.

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