Open Journal of Anesthesiology, 2013, 3, 408-412
Published Online November 2013 (
Open Access OJAnes
Errors during Paediatric Cardiac Anaesthesia: Reporting
and Learning
Mohammad Hamid, Mohammad Irfan Akhtar, Fauzia Nasim Minai, Amar Lal Gangwani
Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan.
Received August 20th, 2013; revised September 21st, 2013; accepted October 2nd, 2013
Copyright © 2013 Mohammad Hamid et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Incident reporting is a reliable quality assurance tool, frequently used in anaesthesia to identify errors. It was introduced
in anaesthesia by Cooper in 1978 and since then several institutions have adopted this system to find adverse events and
near misses. We think that the incident reporting would be more beneficial for prolonged and technically complex pro-
cedures like paediatric cardiac surgery. Methods: All paediatric CHD patients scheduled for cardiac surgery were in-
cluded in this audit. Thoracic and general surgery patients were excluded. Any event in preoperative area, induction
room, operating room and during transfer to cardiac ICU was documented in a predesigned proforma by resident/con-
sultant. This proforma included information regarding demographics, the type and severity and responsible factors for
the event. Results: 134 patients were included in this two and half years audit. 88 patients were male (65.7%) and 46
(34.3%) were female. The age of the patients ranged from one day to 15 years. Total 105 incidents were noticed in 61
patients. 46 incidents were declared as major events which were potentially serious while 59 events were of minor na-
ture. Cuffed endotracheal tube was used in 73% patients. The majority of events occurred in the pre-bypass period.
Most of the incidents were related to cardiovascular system (73%), followed by pharmacological incidents. Human fac-
tors (74%) were mainly responsible for the incidents. Conclusion: Incident reporting is a reliable and feasible method
of improving quality care in developing countries. It helps in identifying areas which need improvement and helps in
developing guidelines to improve safety.
Keywords: Paediatric; Congenital Heart Surgery; Anaesthesia; Errors
1. Introduction
Incident reporting is a reliable quality assurance tool, fre-
quently used in anaesthesia to identify errors. It was in-
troduced in anaesthesia by Cooper [1] in 1978 and since
then several departments have used voluntary incident re-
porting to find adverse events and near misses.
Incident reporting is probably more important for pro-
longed and technically complex procedures like paediat-
ric cardiac surgery which requires longer hospital stay.
Adverse event is a major concern during the management
of paediatric cardiac surgery patients due to the presence
of intracardiac defect, severity of disease and complexity
of surgery in these patients. Errors in medical manage-
ment can occur at several steps including pre bypass,
bypass, post bypass period, during the transfer of patient
to CICU and in the CICU but the possibility of untoward
incident is higher in OR [2] than ICU or wards.
Incident reporting is a well established and an effec-
tive way of identifying these events. Incident reporting
not only helps in identification of actual adverse events
but also near misses and no harm events can be identified.
The severity of the incident affects the outcome of the
patient, ranging from transient damage to full recovery or
increasing length of hospital stay and in the worst cases
We started incident reporting in paediatric congenital
heart disease (CHD) surgery patients with the aim of
improving the quality of care. Critical Incident for this
audit is defined as “An incident that affected or could
have affected, if uncorrected, the safety of patient during
the period of care. Our aim of this audit was to prospec-
tively compile the critical incidents in paediatric cardiac
anaesthesia, review the root cause, analyze and provide
recommendations to improve patient safety.
Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning 409
2. Method
All paediatric CHD patients who were scheduled for car-
diac surgery were included in this audit. Thoracic and ge-
neral surgery patients were excluded. Any event in pre-
operative area, induction room, operating room and dur-
ing transfer to cardiac ICU was documented in a predes-
igned proforma by resident/consultant responsible for
immediate care of patient at that time. Detailed descrip-
tion of incident and suggestions for improvement were
recorded in the predesigned form. This proforma in-
cluded information regarding demographics, the type and
severity and responsible factors for the event.
All statistical analysis was performed using statistical
package of social science version 19 (SPSS Inc. Chicago,
IL). Number of single and multiple incidents of each pa-
tient were counted and presented as “m”. Frequency and
percentages were used to summarize incident character-
istics and other categorical variables as well as differ-
ences in proportion were evaluated by chi-square test.
Median with IQR was estimated for age of patients. Fac-
tors, suggestions, prevention and outcome of incident
were also presented in term of frequency and percentage.
p 0.05 was considered as significant.
3. Results
134 patients were included in this audit of two and half
year period. 88 patients were male (65.7%) and 46
(34.3%) were female (Table 1). The age of the patients
ranged from one day to 15 years with median age of 21
months. Total 105 incidents were noticed in 61 patients.
An average of 0.78 anaesthesia related incidents occurred
in each case. The person reporting the incident scored the
level of harm. 46 incidents were declared as major events
which were potentially serious while 59 events were of
minor nature and not expected to cause serious conse-
Cuffed endotracheal tube was used in 73% patients.
The majority of events occurred in the pre-bypass period.
Most of the incidents were related to cardiovascular sys-
tem (73%), followed by pharmacological incidents (Ta-
ble 2). Difficult intravenous and invasive line access was
noticed in 45 patients leading to delay in starting the sur-
gery and potential for hypothermia. One patient tempo-
rarily developed lower limb ischemia due to femoral ar-
terial spasm after femoral arterial line placement.
Human factors (74%) were mainly responsible for the
incidents and main suggestion was to provide better trai-
ning and education (52.5%) of the residents and medical
officers. These incidents led to major physiological im-
pairment in 6% and morbidity in 4% of patients. There
was no significant association between age of the pa-
tients and timing of the event (p-value: 0.517). We were
also unable to find any association between gender and
Table 1. Descriptive information of the patients and inci-
Detailed n Percentage
Total number of patients (n) 134 -
Total number of incidents (m) 105 -
Incidence of incidents in patients 61 45.5%
Multiple incidents (2) 32
Single incident 29 47.5%
Male 88
Female 46
Mode of Admission*
Elective 122
Emergency 06
Age (months)
Median (IQR) 21(65)
Maximum Age 15 Years
Minimum Age 3.9 Days
Timing of the event (n = 61)
Pre bypass 43 70.5%
Post bypass 18 29.5%
Cuffed 98
Un cuffed 19 14.2%
Not mentioned 17 12.2%
Major Incidence 31 58.8%
Minor Incidence 30 49.72%
*Mode of admission of 6 patients are missing.
severity of incidence. High number of minor incidences
were noticed during pre-bypass period (Table 3) while
major incidences were more common during and after
bypass with p-value of 0.034.
4. Discussion
Errors in medicine are among the 10 leading causes of
death [3]. Incident reporting can play a major role in de-
veloping strategies for improving patient safety. Factors
responsible for the incidents must be identified which
can be a system failure or human factor. The reason
should be identified and recommendations made in a
large group. These audits help in improving the standards
of care and leads to the development of new policies and
Open Access OJAnes
Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning
Table 2. Pediatric congenital heart critical incident (m =
Incidents Count (m)Percentage
Intubation Related Incidents (n = 2) 02 1.9%
Unanticipated difficult intubation 01 0.95%
Bronchospasm 01 0.95%
ETT and Circuit Incident (n = 3) 03 2.8%
Circuit Disconnection 02 1.9%
Other: Leak tube change to large size tube 01 0.95%
Pulmonary Incidents (n = 3) 05 4.7%
Hypoxemia 02 1.9%
Hypercapnia 01 0.95%
Left Lung Collapse 01 0.95%
Wrong route (Intravenous Sildenafil given 01 0.95%
Orally during CPB time, no reaction seen)
Cardiac Incidents (n = 11) 18 17.1%
Cardiac Arrest/CPR 4 3.8%
Bradycardia 5 4.7%
Tachycardia 1 0.95%
Hypotension 6 5.7%
Hypertension 1 0.95%
Others 1 0.95%
Pharmacological Incidents (n = 9) 09 8.5%
Under dosage
Over dosage 01 0.95%
Other: (2 not describe) 04 3.8%
Ceftazidine diluted in vancomycin bag
recognized after dilution not administerd 01 0.95%
Muscle relaxant (Pavulon) changes color after
Dilution so discarded 01 0.95%
Drug Administration at wrong time 01 0.95%
Unnecessary boluses of phenylephephrine 01 0.95%
CVP/IV/A-line insertion
related Incidents (n = 38) 59 56.1%
Carotid puncture 13 12.3%
Hematoma Neck 01 0.95%
Difficult IV 14 13.3%
Difficult A-line 16 15.2%
Difficult CVP 15 14.2%
Monitoring Incidents (n = 5) 05 4.7%
NIBP 01 0.95%
Art-Line 03 2.8%
LA Line 01 0.95%
Vascular Incidents (n = 2) 02 1.9%
Extravasation 02 1.9%
Miscellaneous (n = 2) 02 1.9%
Blood products not available till patients
went on by pass
02 1.9
Values are number and percentage.
Table 3. Association with time of event with Major/Minor
Time of Event
Major Incidence Minor Incidence
Pre bypass 16 (57.1%) 27 (81.8%)
Post bypass 12 (42.9%) 6 (18.2%)
Total 28 33
processes to prevent adverse events in the future [4]. One
such initiative was taken by Society of Cardiovascular
Anesthesia called FOCUS [5] (Flawless Operative Car-
diovascular Unified System) to identify hazards during
cardiac surgery and then develop interventions.
Voluntary and anonymous reporting is helpful in do-
cumenting an event without fear and retribution. At the
same time disadvantage of this type of reporting is that
the importance of event reporting particularly minor in-
cidents, is some how reduced as you are not making it
mandatory to report. Under reporting of incidents is also
a factor and there are multiple reasons for that.
Largest self reported incidents occurred in cardiac sur-
gery to date [6]. Cardiac surgery is associated with
higher incidence of adverse events (12.3%) when com-
pared with all surgical admissions (3%). Type of inci-
dents and harmful incidents differ in OR when compared
with non OR environment. Bates et al. [7] in a prospec-
tive study determined that 25% of deaths among cardio-
thoracic surgery patients are avoidable. 21% of incidents
occurred in the OR in cardiac surgery patients despite the
fact that the patient spends brief time (4 - 6 hrs) of his
hospital stay in the OR.
Paediatric cardiac surgery is most susceptible to errors
[8,9] due to the involvement of multiple specialities,
Open Access OJAnes
Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning 411
changing plans and concurrent tasks. In addition, paedi-
atric cardiac surgery requires coordinated efforts by mul-
tiple individuals, it is complex, require sophisticated equi-
pment and structures and also require technical skills and
cognitive function. Major events are more likely to occur
in these complex and lengthy surgeries. While minor
events are independent of complexity of cases and occurs
in all type of cases [10]. Minor events are usually caused
by miscommunication and distraction. Training of whole
team regarding communication may help.
Minor incidents are commonly under reported because
the reporting person is not aware of the importance or
he/she may be too busy in the management of complex
procedure. Lack of motivation and lack of knowledge
about the importance of this quality assurance tool is
another factor which leads to under reporting. Near
misses [11] should be focused in incident reporting sys-
tem to develop strategies for improvement and reduced
the risk of actual patient harm. Several studies have
shown that near misses occur more frequently than actual
errors or adverse events. Our audit also demonstrates that
the percentage of minor incidences is also high. Incident
reporting should be non punative, voluntary, anonymous
and confidential.
Majority of the incidents in our study are related to
cardiovascular system. Higher incidence of carotid punc-
ture and difficult intravenous and invasive lines was seen
in our patients. The reason for this high incidence was
probably due to inexperienced and lack of skills as first
attempt in most of the cases was made by the resident or
junior medical officers. We included difficult IV and In-
vasive lines as an adverse event because these incidents
have potential for hypothermia, and increase LOS in the
OR. Cardiac arrest is also seen in few patients and all
reverted to spontaneous circulation. According to perio-
perative cardiac arrest reporting [12] (POCA) 34% of all
cardiac arrests occurred in patients with CHD and most
of which having surgeries in general ORs. Mortality after
cardiac arrest in CHD patients was also higher 33% vs
Operating room is potentially a high risk area for me-
dication errors [13] because only anaesthetists are re-
sponsible for administering medications and bypassing
the mechanism of double checking in the wards and ICU
by nurses, pharmacist, physician and computer. But due
to under reporting by anaesthetists the incidence reported
in different studies and in present study as well is low. In
other areas nurses are more vigilant and enthusiastic in
reporting errors. Overdosage was the main adverse phar-
macological event in our patients. Inaccurate entry in the
Graseby pumps by anaesthetists was accounting for these
events. In another incident Sildenafil which was sup-
posed to be given by NG tube was administered intrave-
nously by a resident due to miscommunication. Fortu-
nately the patients were on bypass at that time and it was
given through femoral CVP. We think that most of the
particles were drain by RA cannula into reservoir and
then filtered out by arterial filter. Operating room is a
proved to be a high risk area for adverse events. In a re-
cent study, only 24% of OR errors were medication re-
lated compared with 17% in non OR.
Airway and pulmonary events are important for the
anaesthetists. Most of these events were avoidable with
extra attention and following general guidelines and po-
licies. Change of endotracheal tubes due to smaller size
tube is a common error in paediatric patients but these
was only one case reported in our study. We think this
Table 4. Factors, suggestions and preventions of incident.
Variables FrequencyPercentage
Incident related to (n = 37)
Anaesthesia 30 81.1%
Patient’s pre-existing condition 02 5.4%
Others 05 13.5%
Factors responsible for Incident (n = 46)
Patients Factors 7 15.2%
Equipment Failure 2 4.3%
Human Factors 34 73.9%
Others 3 6.5%
Suggestion for prevention (n = 46)
Additional monitoring or material 1 2.2%
Improved monitoring or material 1 2.2%
Better maintenance of existing
monitoring/equipment 1 2.2%
Improved arrangement of drugs 4 8.7%
Better training/education 24 52.2%
Better working conditions better organization 3 6.5%
Better supervision 3 6.5%
Better communication 2 4.3%
Others(describe) 5 10.9%
Better training/education + Better supervision 1 2.2%
Better supervision + Better
communication + Better quality 1 2.2%
Was the incident preventable? (n = 47)
Probably preventable with current resource 41 87.2%
Possibly preventable with reasonable
extra resources 3 6.4%
Not obviously preventable by any
change in practice 3 6.4%
Open Access OJAnes
Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning
Open Access OJAnes
has been under reported and this needs to be emphasize
in group meetings [14].
Equipment related errors [15] are high in cardiac an-
aesthesia in comparison to non cardiac group (37% vs
9%). Very low incidence of equipment failure leading to
monitoring errors in our study is also due to under re-
porting. ECG monitoring problem is very common in
paediatric cardiac surgery but we no such incident is
mentioned in any patient. Anaesthetists unusually avoid
mentioning such minor but incidences which could have
caused disastrous results.
Human error was the major responsible for the events
in our study (Table 4). These events were of minor na-
ture. Factors like judgement errors, lack of experience
and skills and miscommunication were identified. Most
of the invasive lines were started by junior residents in
paediatric CHD patients. These were closely supervised
by the consultants but still we have seen higher incidence
of carotid puncture and delays in inserting invasive lines.
Human factors includes error of judgement, failure to
check, technical failure of skills, lack of care, inexperi-
ence, inattention or delusion, communication and teach-
Chance of error correction is usually possible in pre-
bypass period but correction is difficult during bypass
and post bypass period. Present audit has also shown that
most of the major incidents occurred during this time,
which in few cases led to major physiological derange-
ment and morbidities.
5. Conclusion
Present article provides support for the idea of imple-
menting Incident reporting as a quality assurance tool in
developing countries as well. It is cheap, feasible and
helps in identifying areas which need improvement. On
the basis of these findings, we can develop quality im-
provement guidelines to enhance patient safety.
[1] J. B. Cooper, R. S. Newbower, C. D. Long and B. Mc-
Peek, “Preventable Anesthesia Mishaps: A Study of Hu-
man Factors,” Anesthesiology, Vol. 49, No. 6, 1978, pp.
[2] A. A. Gawande, M. J. Zinner, D. M. Studdert and T. A.
Brennan, “Analysis of Errors Reported by Surgeons at
Three Teaching Hospitals,” Surgery, Vol. 133, No. 6, 2003,
pp. 614-621.
[3] L. Homsted, “Institute of Medicine Report: To Err Is Hu-
man: Building a Safer Health Care System,” The Florida
Nurse, Vol. 48, No. 1, 2000, p. 6.
[4] P. Sirivararom, T. Virankabutra, N. Hungsawanich, P.
Premsamran and W. Sriraj, “The Thai Anesthesia Inci-
dents Monitoring Study (Thai AIMS) of Adverse Events
after Spinal Anesthesia: An Analysis of 1996 Incident
Reports,” Journal of the Medical Association of Thailand,
Vol. 92, No. 8, 2009, pp. 1033-1039.
[5] E. A. Martinez, J. A. Marsteller, D. A. Thompson, et al.,
“The Society of Cardiovascular Anesthesiologists’ FO-
CUS Initiative: Locating Errors through Networked Sur-
veillance (LENS) Project Vision,” Anesthesia & Analge-
sia, Vol. 110, No. 2, 2010, pp. 307-311.
[6] E. A. Martinez, A. Shore, E. Colantuoni, et al., “Cardiac
Surgery Errors: Results from the UK National Reporting
and Learning System,” International Journal for Quality
in Health Care, Vol. 23, No. 2, 2011, pp. 151-158.
[7] D. W. Bates, D. J. Cullen, N. Laird, et al., “Incidence of
Adverse Drug Events and Potential Adverse Drug Events,
Implications for Prevention. ADE Prevention Study Group,”
The Journal of the American Medical Association, Vol.
274, No. 1, 1995, pp. 29-34.
[8] P. Barach, J. K. Johnson, A. Ahmad, et al., “A Prospec-
tive Observational Study of Human Factors, Adverse
Events, and Patient Outcomes in Surgery for Pediatric
Cardiac Disease,” The Journal of Thoracic and Cardio-
vascular Surgery, Vol. 136, No. 6, 2008, pp. 1422-1428.
[9] S. K. R. Catchpole, A. E. Giddings, M. R. de Leval, et al.,
“Identification of Systems Failures in Successful Paediat-
ric Cardiac Surgery,” Ergonomics, Vol. 49, No. 5-6, 2006,
pp. 567-588.
[10] R. P. Mahajan, “Critical Incident Reporting and Learn-
ing,” The British Journal of Anaesthesia, Vol. 105, No. 1,
2010, pp. 69-75.
[11] M. Ricci, A. P. Goldman, M. R. de Leval, G. A. Cohen, F.
Devaney and J. Carthey, “Pitfalls of Adverse Event Re-
porting in Paediatric Cardiac Intensive Care,” Archives of
Disease in Childhood, Vol. 89, No. 9, 2004, pp. 856-859.
[12] J. M. Steven, “Congenital Heart Disease and Anesthe-
sia-Related Cardiac Arrest: Connecting the Dots,” Anes-
thesia & Analgesia, Vol. 110, No. 5, 2010, pp. 1255-1256.
[13] A. D. Paix, M. F. Bullock, W. B. Runciman and J. A.
Williamson, “Crisis Management during Anaesthesia: Pro-
blems Associated with Drug Administration during An-
aesthesia,” Quality & Safety in Health Care, Vol. 14, No.
3, 2005, p. E15.
[14] R. Maaloe, M. la Cour, A. Hansen, et al., “Scrutinizing
Incident Reporting in Anaesthesia: Why Is an Incident
Perceived as Critical?” Acta Anaesthesiologica Scandi-
navica, Vol. 50, No. 8, 2006, pp. 1005-1013.
[15] M. Chakravarthy, “Errors in Cardiac Anesthesia—A De-
terrent to Patient Safety,” Annals of Cardiac Anaesthesia,
Vol. 13, No. 2, 2010, pp. 87-88.