INCIDENTS IN OBSTETRIC ANAESTHESIA: A FIVE YEARS ANALYSIS OF SENSAR REPORTS
   
Background and Goal of Study: Certain factors might provide the “perfect storm” for and adverse obstetric incident; many events, usually unexpected, lead to rapid assembly of a team in what often appears to be a chaotic situation. “Spanish notification system on safety issues of anaesthesia and intensive care (SENSAR)” collects information on more than 5000 incidents from 86 Spanish hospitals. Local analysis of the incidents allows identification and prevention of errors and their contributing factors. We aimed to review the underlying factors that led to an obstetric incident and different actions implemented after the analysis. 

Materials and Methods: Data were collected retrospectively from all obstetric incidents reported to SENSAR database in the past 5 years 

Results and Discussion: 100 incident reports were reviewed. The median age of patients was 32 years (95%CI 31,14-33,08). 61% were classified as ASA 1 (95%CI 50,7-71,1). Regional anaesthesia was the most commonly used technique (76%, 95%CI 66,4-84,2). The majority of incidents resulted in no harm to patients (72%, 95%CI 63,1-80,9). Most of the incidents (72%) were reported by medical specialists; directly responsible in 47%. The most frequent types of incidents were “clinical” (27%), “equipment related” (27%) and “medication error” (24%), being “equipment failure” the most recurrent subtype (12 cases). “ Safety practice problem” was the most common active error (24%, 95%CI 15,5-32,5) , whereas “safety culture related problem” (42%) and “communication error” (22%) were the most prevalent latent risk factors. 2 or more latent risk factors were present in 83% of incidents (95%CI 75,5-90,5), with a median of 3 latent risk factors and IQR 4. Lastly, measures were implemented in 96% of the cases, being “safety related session" the most common (63%).

Conclusions: Most of the patients that suffered an obstetric incident were young , ASA 1, and received regional anaesthesia. Contrary to what was expected, no time slot was associated with an increased risk and the urgency of the procedure was only involved in few cases. However, human factors like miscommunication and lack of safety awareness were involved in most cases, this highlights the importance of non technical skills training. Even thought the majority of incidents resulted in no harm, preventive measures were implemented in a high percentage. Incident reports and analysis can reduce risks and improve patient safety.

Incidents in obstetric anaesthesia: a five years analysis of SENSAR reports