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Adverse Events & Critical-Incident Management in Anaesthesia
Definitions
| Term | Working definition | Key legal reference (SA) |
|---|---|---|
| Adverse Event (AE) | Unintended injury or complication that results in disability, prolonged hospital stay or death and is caused by healthcare management rather than the patient’s underlying disease. | DoH National Patient-Safety Incident (PSI) Guideline v2 (2022) |
| Serious Reportable Incident | AE that leads to death, loss of function, or is likely to attract media/public attention. | NHLS/NDoH PSI taxonomy |
| Procedure-related death | Death occurring during or as a result of any diagnostic, therapeutic or palliative procedure, irrespective of time delay. | Health Professions Amendment Act 29 of 2007 §48 |
| Adverse Drug Reaction (ADR) | A noxious, unintended response to a medicine that occurs at any dose, including errors, misuse or overdose. | SAHPRA Vigilance Guideline v4 (2024) |
Immediate Response Algorithm–“10 C’s”
| C-step | Actions |
|---|---|
| Call help | Second anaesthetist, resus trolley, rapid-response team. |
| Care for patient | Allocate primary clinician to airway/ventilation; secondary to drugs/lines. |
| Command (Incident Supervisor) | Senior anaesthetist takes charge, allocates tasks, verifies critical steps (tube position, monitors, machine). |
| Close theatre | Stop list; restrict entry; quarantine equipment. |
| Collect evidence | Do not turn off monitors; print waveforms; photograph screens; bag/label syringes, ampoules, disposables. |
| Console relatives | Joint surgeon–anaesthetist disclosure; honest facts, no blame, clear next steps. |
| Contact hospital risk & insurer | Notify PSI officer, theatre matron; phone MPS/Ethiqal before formal statements. |
| Chart | Contemporaneous narrative, exact times, team roster; attach print-outs. |
| Counsel team | Hot debrief within two hours; psychological first aid; roster flexibility. |
| Continue review | Follow patient post-event; update family; prepare for cold M&M, GW 7/24 etc. |
Mandatory Forms & Reporting (Timeline) in South Africa
| Timeframe | Form | Completed by | Destination |
|---|---|---|---|
| Immediately | PSI notification (electronic) | Theatre unit manager | National PSI system |
| < 24 h | GW 7/24 Parts A–C (anaesthetic/procedure deaths) | Anaesthetist / Surgeon / HoD | Provincial Forensic Pathology Services |
| DHA-1663 death certificate | Certifying doctor | Dept. Home Affairs | |
| FPS 100 body referral | Theatre nurse | Forensic mortuary | |
| MDNF (maternal only) | Obstetric clinician | District MCH office | |
| < 48 h | GW 7/24 Part D (institutional review) | HoD | FPS & DoH |
| < 3 d | Insurer report | Responsible clinician | MPS / Ethiqal |
Analysis & Learning
Structured Methods
| Tool | Purpose | Output |
|---|---|---|
| Root-Cause Analysis (RCA) | Finds single most proximate cause. | Fishbone diagram, action plan. |
| London Protocol | Systems analysis: patient, task, team, workspace, org & culture. | List of contributory factors + safety recommendations. |
| Human Factors–Swiss-Cheese model | Differentiates latent vs active failures. | Safety-barrier map. |
| Treat-&-Error (threat–error management) | Prospective mapping of threats and human errors. | Simulation scenarios, checklists. |
Just-Culture Grid
| Behaviour | Response |
|---|---|
| Human error (slip, lapse) | Console, support, systems fix. |
| At-risk behaviour (work-around) | Coaching, education. |
| Reckless behaviour | Disciplinary / regulatory action. |
Adverse Drug Reactions & Medication Safety
ABCDEF Classification
| Type | Example (anaesthesia) | Prevention / Response |
|---|---|---|
| A Augmented (dose-related) | Hypotension with propofol bolus | Titrate, adjust weight-based dose |
| B Bizarre (idiosyncratic) | Anaphylaxis to rocuronium | Avoid agent, prepare Kit A |
| C Chronic | HPA suppression from prolonged steroids | Limit dose, taper |
| D Delayed | Post-op cognitive decline after anaesthesia | Prevention techniques |
| E End-of-use | Clonidine withdrawal hypertension | Step-down patch strength |
| F Failure | OCP failure with midazolam CYP3A induction | Counsel, alter anaesthetic plan |
High-impact Safety Recommendations (evidence graded)
| Rank | Intervention | Evidence level |
|---|---|---|
| ★★★ | Read syringe/ampoule twice before draw-up | Strong (RCT & observational) |
| ★★★ | Label every syringe immediately after drawing | Strong |
| ★★★ | Colour-coded, pre-printed drug class labels (ISO 26825) | Strong |
| ★★ | Double-check with second person or barcode | Moderate |
| ★★ | Standardise tray layout (routine vs emergency) | Moderate |
| ★ | Prefilled syringes for emergency drugs | Emerging |
| ★ | Smart pumps with drug library & hard limits | Emerging |
- (Adapted from ANZCA PS51 2022, ASA 2023 Safe Drug Administration statement.)
Debrief & Staff Well-being
- Hot debrief–within two hours, facilitator uses IF SPOTS mnemonic (Introduction, Facts, … Support).
- Cold debrief / M&M–within 7 days, use structured form; invite all disciplines.
- Second-victim support–confidential counselling, buddy system, phased return to work.
Links
Past Exam Questions
Prevention of Oxygen Cylinder Injury in the MRI Scanner
An adverse incident of oxygen cylinder injury to a patient in the MRI scanner has occurred in your hospital. The patient was transported from the intensive care unit.
Explain the different ways that the incident should be prevented in future (10)
References:
- Adyanthaya, S. S. and Patil, V. (2014). Never events: an anaesthetic perspective. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 14(5), 197-201. https://doi.org/10.1093/bjaceaccp/mkt055
- Adapted from Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet 2000;356:1255-9.
- South African Society of Anaesthesiologists. Adverse Event Reporting & Management Guidelines. 2024.
- Department of Health. National Patient Safety Incident Reporting & Learning Guideline v2. 2022.
- Health Professions Amendment Act 29 of 2007 (Section 48).
- ANZCA. Professional Document PS51: Safe Administration of Injectable Drugs in Anaesthesia. 2022.
- International Organization for Standardization. ISO 26825: User-applied Drug Labels in Anaesthesia. 2021.
- ASA Committee on Patient Safety. Statement on Medication Safety in the Operating Room. 2023.
- South African Health Products Regulatory Authority. Vigilance Guideline v4. 2024.
- Reason J. Human error: models and management. BMJ 2000;320:768-70.
- Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. National Academies Press; 2000.
Summaries:
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