Anesthesia-related complications remain a significant concern, since the first recorded anesthetic-related death in 1848^[1], particularly in emergency surgical settings where time constraints, limited patient preparation, and urgent decision-making increase the risk of adverse outcomes. Despite major advancements in anesthetic techniques and monitoring systems, the exact incidence and primary causes of anesthesia-related morbidity and mortality in emergencies remain inadequately defined^[2,3].

Critical incident monitoring is a recognized tool for enhancing patient safety by identifying preventable errors and system failures. Originally developed by Flanagan^[4] in 1954 and later adapted for anesthesia by Cooper et al.^[5] in 1978, this approach analyzes incidents that either led to or could have led to undesirable outcomes. Although well-established in elective surgical settings^[6,7], its application in emergency anesthesia is less explored.

Existing literature primarily addresses surgical and patient-related risk factors^[8-10], with limited focus on human and system-related errors specific to anesthetic management in emergencies. This study aims to evaluate the frequency, nature, and contributing factors of critical incidents reported during emergency surgeries, using a structured reporting system to gain insights that could inform targeted safety interventions in high-risk, time-sensitive environments.

AIM AND OBJECTIVES

The aim of this study was to determine the incidence, outcomes, and potential risk factors contributing to critical incidents during anesthesia in emergency surgeries in a general tertiary care teaching hospital. Additionally, the study aimed to encourage and promote the voluntary reporting of critical incidents within the department.

PRIMARY OBJECTIVE: To determine the frequency of peri-anesthetic critical incidents in patients undergoing emergency surgical procedures.

SECONDARY OBJECTIVE: To analyze the causes and risk factors associated with critical incidents and propose preventive strategies to enhance patient safety.

STUDY DESIGN: Descriptive study

STUDY PERIOD: From June 2023 - June 2024 STUDY DURATION: One year

INCLUSION CRITERIA: Patients of all age undergoing emergency surgery

EXCLUSION CRITERIA: Nil

PROCEDURE

The study was conducted in a tertiary care teaching hospital for a period of 1 year and included patients of all age undergoing emergency surgery. It was a prospective observational study approved by the institutional ethics committee. Since it was an observational study without any intervention, consent from the patient was not required. A critical incident in anesthesia is defined as any untoward and preventable mishap associated with the administration of general or regional anesthesia, and which leads to, or could have led to an undesirable patient outcome ^[11]. A near miss is an event under anesthesia care which has the potential to lead to the substantial negative outcome if left to progress^[12]

An indigenously designed form (Google form) was used for data collection. The forms were made available at each study site. All the Anaesthesiology Junior residents were briefed on the objectives and working definitions utilized for the study. They were encouraged and reminded regularly to report incidents that they witnessed, within 72 hours of their occurrence voluntarily. Patients’ name and reporting residents name were not collected. The promise of anonymity and confidentiality was emphasized and they were reassured that no punitive actions would be taken. The filled forms were submitted for collection and study

In our study, 22 (1.64%) patients had critical incidents out of 1334 patients who underwent emergency surgery.

The following table shows the distribution of critical incidents among various demographics and its anesthesia characteristics.

Table 1: Demographic variables and anaesthesia characteristics for critical incidents

DISTRIBUTION OF CRITICAL INCIDENTS:

Chart 1: Airway related incidents

Chart 2: Cardiovascular related incidents

Chart 3: Drug related incidents

Chart 4: Regional technique related incidents

Chart 5: Probable cause of critical incident

Chart 6: Human factor

Chart 7: Patient outcome

The predominance of critical incidents among young adults (19–30 years) may reflect the higher proportion of this age group undergoing emergency surgeries in the study population. Young adults are often involved in trauma, obstetric, and acute surgical emergencies, which may account for their increased representation. The lower incidence among infants and the elderly may be attributed to more selective surgical indications, heightened perioperative vigilance, or fewer emergency procedures being performed in these age groups at our center [Table 1]. Nevertheless, the presence of incidents across all age categories underscores the importance of vigilant anesthetic care irrespective of patient age.

There is predominance of females in critical incidents [Table 1], where obstetric emergencies—commonly requiring urgent anesthetic interventions—constitute a substantial proportion of emergency surgical workload. Additionally, conditions such as ruptured ectopic pregnancy or emergency cesarean sections may contribute to the higher representation of females in this dataset. This trend highlights the need for targeted strategies and preparedness in managing high-risk obstetric cases under emergency anesthesia.

The majority of patients who experienced critical incidents were otherwise healthy, with no co-morbidities [Table 1], indicating that critical events in emergency anesthesia may occur independently of underlying medical conditions. This highlights the influence of other factors such as the urgency of surgery, procedural complexity, or system-related and human errors. The small proportion of patients with known co-morbidities suggests that vigilance should be maintained across all patient categories, regardless of pre-existing health status.

The predominance of ASA II patients suggests that critical incidents are not confined to high-risk (ASA III–IV) individuals but are also prevalent among patients with mild systemic disease [Table 1]. This finding may indicate that patient risk alone is not the sole determinant of incident occurrence. The emergency nature of surgeries, combined with time constraints and limited optimization opportunities, may increase vulnerability even in moderately healthy patients. Therefore, meticulous attention is essential regardless of ASA grade, particularly in emergency settings.

The high proportion of critical incidents in obstetric and gynecologic emergencies may be attributed to the urgent nature of such cases, where rapid decision-making, limited patient preparation, and physiological changes during pregnancy increase anesthetic risk. General surgical emergencies, being diverse and often complex, also contribute significantly. The lower incidence in pediatric and ENT cases may reflect fewer emergency procedures or enhanced preparedness in these specialties. [Table 1]

Critical incidents occurred slightly more frequently during the daytime (54.5%) than at night (45.5%). However, the difference is relatively small, indicating that critical incidents are not confined to a specific time of day and may occur during both shifts. This underscores the need for strict vigilance throughout the 24-hour cycle in emergency anaesthesia settings.

The predominance of spinal anesthesia among reported incidents [Table 1] may be linked to its widespread use in obstetric and lower abdominal emergency surgeries, where it is often the first-choice technique. Despite its advantages, spinal anesthesia carries risks such as hypotension, high spinal block, and technical failures, especially in time-pressured emergency scenarios. Incidents with combined or general anesthesia may reflect more complex or higher-risk cases. These findings underscore the importance of careful patient selection, technique execution, and monitoring, particularly when regional anesthesia is employed in emergencies.

The fact that over three-fourths of the incidents occurred during the anesthetic procedure [Table 1] highlights this phase as particularly vulnerable in emergency settings. Factors such as limited preparation time, rapid sequence induction, technical challenges, or unfamiliar patient status may contribute to this increased risk. Incidents during emergence and surgery, though fewer, still reflect the importance of maintaining vigilance throughout the perioperative period. These findings reinforce the need for protocol-driven, team-based approaches and heightened situational awareness, especially during anesthesia administration in emergencies.

Airway-related incidents, [Chart 1] though relatively infrequent, pose significant risks in emergency anesthesia due to time-sensitive decision-making and potential for rapid patient deterioration. Incomplete reversal may reflect hurried extubation, inadequate monitoring, or drug errors, while difficult intubation underscores the challenge of securing the airway in less-than- ideal conditions. These findings stress the importance of adhering to extubation criteria, utilizing neuromuscular monitoring, and ensuring the availability of advanced airway management tools and trained personnel in emergency settings.

Cardiovascular events such as bradycardia and hypotension are common anesthetic complications [Chart 2], particularly in emergency scenarios where rapid hemodynamic shifts may occur. The use of neuraxial blocks (e.g., spinal anesthesia), patient comorbidities, or inadequate volume resuscitation may contribute to these events. Prompt recognition and management are essential to prevent progression to life-threatening instability. These findings reinforce the need for proactive monitoring and readiness to intervene during high-risk periods, especially in patients receiving regional anesthesia.

While venous access difficulty was infrequent, it highlights the challenges faced in emergency settings, particularly in dehydrated or hypotensive patients. Drug administration errors, though individually uncommon, represent a significant safety concern due to their potential for severe patient harm [Chart 3]. There was one case where epidural test dose was given without fixing the catheter at the desired level. Errors in dosing and timing, especially involving epidural medications, may stem from communication lapses, lack of standardized protocols, or high workload pressures during emergencies. These findings emphasize the need for stringent drug verification processes, standardized checklists, and enhanced training in crisis resource management.

A single respiratory event (4.5% of cases) was documented, specifically involving laryngospasm and apnea, both of which are significant anesthetic complications. While the frequency appears low, these events are potentially life-threatening and require immediate intervention. This underscores the importance of careful airway management and readiness to manage complications in emergency surgical settings, especially when general anesthesia or airway manipulation is involved.

Spinal anesthesia-related issues dominate the complications [Chart 4], especially failed spinal and high spinal, underscoring the need for greater precision and experience in administering regional blocks, particularly in emergencies. Technical errors such as choosing the wrong needle size or repeated epidural attempts may increase patient risk and procedural time. Dural punctures, though less frequent, are clinically significant as they can lead to post-dural puncture headaches and potential neurologic sequelae. These findings suggest a clear need for enhanced training to minimize regional anesthesia-related complications in high-stakes emergency settings.

This study reveals that human factors are the predominant cause [Chart 5], contributing to 81.8% of all events. This overwhelming proportion underscores the critical importance of human performance in the anesthetic process, particularly under the high-pressure conditions typical of emergency settings. Factors such as fatigue, inexperience, miscommunication, and lapses in judgment may significantly contribute to this high incidence.

Pharmacological factors, which account for 9.1% of incidents, suggest that drug-related issues—such as incorrect dosage, drug interactions, or delayed recognition of adverse reactions— also pose a noteworthy risk. There were 2 reported cases of drug failure after spinal anaesthesia requiring respinal. This highlights the importance of double-checking drug labels for expiry dates, dose and enhancing vigilance in drug administration during emergencies.

Equipment-related incidents, although less frequent at 4.5%, can have serious implications, especially when malfunction or misuse occurs in critical moments. There was one reported case where leaky spinal syringe lead to inadequate level of sensory blockade. Regular maintenance, proper equipment checks, and staff training on the use of anesthetic devices are vital preventive strategies.

Similarly, surgical factors contributing to 4.5% of incidents suggest that intraoperative decisions or complications may indirectly lead to anesthetic challenges. There was one case of inadvertent bowel injury in a patient leading to prolongation of surgery which required intubation. This indicates the need for seamless coordination between the surgical and anesthetic teams to manage such events effectively.

Overall, the findings stress the importance of targeted interventions focusing on human factors—such as simulation training, adherence to safety protocols, and improved team communication—to minimize the risk of critical incidents. Additionally, institutional measures such as regular audits, root cause analysis of adverse events, and ongoing professional development can further improve patient safety in emergency anesthesia settings.

Among human factors, “Lack of skill” is the most significant contributor, accounting for over half (54.5%) of the incidents [Chart 6]. This finding highlights a crucial gap in training or experience among anesthesia providers in emergency settings. The complexity and urgency of emergency surgeries demand rapid decision-making and proficient technical skills—areas where deficiencies can have serious consequences.

“Failure to check/detect” (13.6%) represents another key issue, suggesting that lapses in vigilance or oversight—such as not verifying equipment, drug dosages, or patient status—can lead to preventable errors. This underscores the need for strict adherence to safety protocols and checklists, even under time pressure.

“Improper technique” (9.1%) and “Lack of judgement” (4.5%) further reflect the impact of human performance limitations, possibly due to stress, fatigue, or inadequate situational awareness in emergencies.

A majority of patients (63.6%) experienced no serious complications [Chart 7], suggesting that most critical incidents were either mild, well-managed, or did not result in adverse patient outcomes. Prolonged procedures (18.2%) occurred in a significant number of cases. This may reflect the added time needed to manage intraoperative complications or delays caused by human, pharmacological, or equipment-related factors. Recovered (9.1%) and delayed recovery (9.1%) reflect that while some patients did face temporary adverse effects, they eventually stabilized— indicating that even when complications arose, recovery was generally achievable with proper management.

SUMMARY

Among 1,334 emergency surgery patients, 22 (1.64%) experienced critical incidents. Most were young adults aged 19–30 years (63.6%) and female (72.7%), with obstetrics and gynecology cases accounting for over half of the incidents. The majority (72.7%) had no co-morbidities, and 77.3% were ASA II. Spinal anesthesia was involved in 50% of the cases, and most incidents (77.3%) occurred during the anesthetic procedure. Cardiovascular issues (18.2%) such as bradycardia and hypotension, airway complications (13.6%), and drug-related errors (13.6%) were among the common types of incidents. Regional anesthesia-related problems—particularly failed spinal and high spinal blocks—were frequently reported. Human factors were the leading cause (81.8%), especially due to lack of skill (54.5%). Despite these incidents, 63.6% of patients had no serious complications, while some experienced prolonged procedures or delayed recovery.

This study reveals that critical incidents during emergency surgeries, though infrequent, are significant due to their potential impact on patient safety and outcomes. The predominance of incidents among young, otherwise healthy patients (mainly ASA II) suggests that even individuals without major comorbidities are vulnerable, likely due to the urgent and often unpredictable nature of emergency procedures. The high proportion of cases from the Obstetrics and Gynaecology department reflects the challenging and time-sensitive nature of obstetric emergencies, where rapid decisions under pressure can heighten anesthetic risk.

Spinal anesthesia was the most commonly associated technique, indicating the need for greater caution and expertise when using regional methods in emergencies. Most incidents occurred during the administration of anesthesia, highlighting this as a particularly vulnerable period that demands heightened vigilance, especially in high-stress situations.

Human factors, particularly lack of skill and failure to detect errors, were the leading contributors, underscoring the critical importance of adequate training, supervision, and adherence to safety protocols. Though most incidents did not result in serious complications, a notable number led to prolonged procedures or delayed recovery, signaling room for improvement in both prevention and crisis management.

Overall, the findings emphasize the importance of strengthening human performance through simulation-based training, systematic checks, and improved communication in emergency settings. Investing in these areas can substantially reduce preventable errors and improve patient safety in anesthetic practice.

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