Abstract No.: ABS0601: Patient Safety Incidents in Neuro-Anaesthesia “ A Prospective Analysis Over a One Year Period

BACKGROUND & AIMS: Reporting critical incidents and near misses is an established method of improving patient safety; which allows implementation of changes to prevent similar incidents from re-occurring. Our study aimed at identifying and analysing patient safety incidents in the neurosurgical patients. METHODS: We conducted a prospective observational record-based study of all the patients receiving anaesthesia in the Neurosurgery OT over a period of 1 year. Any patient safety incidents occurring in the peri-operative period were noted down by the qualified anaesthetist on the table, which was recorded by the anaesthetists anonymously. Using a secondary database collection method, data already recorded in Anaesthesia register and the perioperative anaesthesia record was used to assess the validity of that data which was be confirmed by critical review. RESULTS: 1901 individuals received anaesthesia for neurosurgical procedures. Incidence of patient safety events was 24.14% (478). 22.59% (108) were near miss events. The incidence of patient safety incidents was the highest during “positioning”™ 19.66% (94). 76.15% (364) incidents were labelled as potentially preventable, 65.34% (312) were anticipated incidents. 68 patients recovered with deficit, 5 were successfully resuscitated, and 3 deaths were reported. A few uncommon incidents were also noted. CONCLUSION: Incidence of critical incidents was almost one for every four patients. The proportion of reported near misses was much lowerthan adverse events. The audit helped us establish policy guidelines in our institution and institute Patient safety training to promote voluntary reporting.