British Journal of Anaesthesia 96 (6): 71521 (2006)

doi:10.1093/bja/ael099

CLINICAL PRACTICE
Adverse events in anaesthetic practice: qualitative study of
definition, discussion and reporting
A. F. Smith1,*, D. Goodwin2, M. Mort2 and C. Pope3
1

Department of Anaesthesia and 2Institute for Health Research, Lancaster University, Lancaster LA1 4YT,
UK. 3School of Nursing and Midwifery, Southampton University, Highfield, Southampton SO17 1BJ, UK
*Corresponding author: Royal Lancaster Infirmary, Lancaster LA1 4RP, UK. E-mail: andrew.f.smith@mbht.nhs.uk
Background. This study aimed to explore how critical and acceptable practice are defined in
anaesthesia and how this influences the discussion and reporting of adverse incidents.

Results. The educational value of discussing events was well-recognized; 28 events were
discussed at departmental meetings, of which 5 (18%) were presented as critical incidents.
However, only one incident was reported formally. Our observations of anaesthetic practice
revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were
acknowledged as offering the potential to improve safety, although some were direct violations of
acceptable practice. Formal reporting appears to be constrained by changing boundaries of what
might be considered critical, by concerns of loss of control over formally reported incidents and
by the perception that reporting schemes outside anaesthesia have purposes other than education.
Conclusions. Despite clear official definitions of criticality in anaesthesia, there is ambiguity in
how these are applied in practice. Many educationally useful events fall outside critical incident
reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but
the reluctance to adopt a more explicit systems approach to adverse events may impede
further gains in patient safety in anaesthesia.
Br J Anaesth 2006; 96: 71521
Keywords: anaesthetists, risks; complications; complications, accidents; incident reporting;
safety, patients
Accepted for publication: March 2, 2006

The specialty of anaesthesia pioneered incident reporting in

healthcare, transferring the concept from other high-risk
industries such as aviation.1 In the UK, the Royal College
of Anaesthetists (RCA) has both provided a widely used
working definition of a critical incident (a critical incident
is one which could have led to harm; it could have been
prevented by a change of process) and endorsed a reporting
template.2 Incident reporting is now being more widely
promoted. Many hospitals have had generic clinical incident reporting schemes in operation for some years and
now a national system for reporting of adverse incidents
and near misses has been established by the National Patient
Safety Agency (NPSA).3 4 Despite this widespread promotion
of incident reporting, little attention has been paid to how

potential threats to patient safety are recognized, defined,

discussed and reported in actual clinical practice. If incident
reporting is to achieve the same potential in healthcare as it
has in other industries, the professional cultural factors affecting the use of such systems must be understood5 but these
have hitherto not been widely explored. We aimed to describe
the factors affecting these practices within the specialty of
anaesthesia.

Methods
Approval for the project from which these data are drawn6
was granted by two local Research Ethics Committees. The

The Board of Management and Trustees of the British Journal of Anaesthesia 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

Method. We conducted workplace observations of, and interviews with, anaesthetists and
anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively
for adverse events in anaesthetic process witnessed. We also observed departmental audit
meetings and analysed meeting minutes and report forms.

Smith et al.

critical incidents taking place during the study period to

talk in more detail about them to our researcher. Interviews
were tape-recorded and transcribed.
The qualitative analysis began with individual close readings and annotations of the observational and interview
transcripts by each member of the research team. This
was followed by collective discussions and comparison of
the various readings of the data, from which our analytical
themes and categories emerged.10 Four anaesthetists
were involved in respondent validation11 of themes arising
from project data. Documentary analysis of audit meeting
minutes and critical incident forms was also undertaken.

Results
We have data from 19 interviews and over 130 h of observation of anaesthetic practice, gathered at the rate of approximately three sessions per month over a year. Although two
of our interviews were debriefing interviews, where anaesthetists were questioned about their work immediately after
being observed, most interviews were unconnected with a
specific theatre session. At the time of our study there were
13 consultant anaesthetists and 10 trainees at the principal
study site. None declined to be observed, although two did
not wish to be interviewed when invited. We interviewed
12 anaesthetists (7 consultants and 5 trainees), 4 ODPs and
3 nurses (2 working in the recovery room and 1 in anaesthesia). Observation included 31 operating theatre sessions
of a variety of different types of surgery and a mixture of
practitioners of varying experience. During these we
observed 53 anaesthetics.

What is a critical incident?

Our interview data show that respondents were aware of the
official definition. However, they had personal, working
interpretations of this official statement. One working
definition related to speed of onset and potential severity.
Hence, a recovery sister described an incident where a
patient, who had had an epidural injection performed by
an orthopaedic surgeon, rapidly became bradycardic and
hypotensive. The patient had no i.v. cannula to enable resuscitation and the recovery staff asked urgently for help from
an anaesthetist in another theatre. Another factor bearing
on definition, related to the feeling of control over a given
situation. In one interview extract (see Supplementary data
for Appendix 1), a senior house officer (SHO) talks of situations becoming critical when he is unable to cope on his
own, where the patients condition was deteriorating beyond
his control. He also recounts an incident that had occurred
earlier on the day of interview, where a leak had developed
in the breathing system. He and his supervising consultant
had rapidly detected and corrected the problem. The SHO
comments: We were just doing our job and being observant, suggesting that such events are an integral part of

716

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

study was conducted principally in one English district general hospital, with shorter periods of observation at a second
English hospital. We used an ethnographic approach,
grounded in detailed observation,7 followed by a series of
in-depth interviews. Ethnography is a form of social
research carried out in everyday settings, using a range of
methods to focus on the meanings of individuals actions and
explanations rather than their quantification.8 The aim is to
build up a picture of the phenomena under study which
makes sense to those who are being studied but which
also allows, along with other qualitative approaches, for
the inductive development of more general theories.9 The
study focused mainly on the operating theatre environment,
and included observation of, and interviews with, anaesthetists, operating department practitioners (ODPs), theatre
and recovery nurses. Participants were recruited from the
anaesthetic staff in the study hospital through a series of
presentations to the anaesthetic department and theatre
staff, outlining the aims of the research and inviting clinicians
to take part. Regular meetings were held thereafter to inform
all staff of progress of the study and to secure their continued
co-operation. For comparative purposes a shorter period of
observation was undertaken at a second site.
The staff participating in the study did so freely. Anaesthetists were asked well in advance of proposed observation
sessions if we might observe them at work. At the time of
the study, the UK research governance regulations requiring
written consent from NHS staff taking part in research had
not yet come into force. Patients on the operating lists were
informed orally and in writing of the study and their written
consent obtained.
Observation was performed without audio or video
recording. Detailed contemporaneous notes were obtained
during the observation period and transcribed immediately
afterwards. Observations were performed principally by the
research associate D.G. (a former anaesthetic nurse). C.P.
(a medical sociologist) and M.M. (a sociologist of science
and technology) performed two and five observations
respectively in tandem with D.G. to allow comparisons
and internal validity checks on the data collection. Most of
the observation took place in the operating theatre, starting
when anaesthetists began their work in the anaesthetic
room, although some observations were made of anaesthetists performing preoperative assessment. As the principal
researcher had been an anaesthetic nurse in the department
where she conducted the observations, staff were used to
her presence and she was also able to position herself where
she could note what was happening without being in the
way. We were also able to observe two departmental audit
meetings and gain access both to departmental critical
incident reports and to the minutes of the remaining
10 meetings.
In our early interviews, to help participants describe how
they used and acquired anaesthetic knowledge (the focus of
the main study6), we asked them to recount a recent case, or
on-call period. We also invited anaesthetists involved in

Adverse events in anaesthetic practice

The potential for adverse events in

anaesthetic practice
During our observations, we did not observe any incidents
where patients were harmed. However, we witnessed a

number of events which, depending on the definition of

criticality, could be construed as reportable (Table 1). For
instance, we observed the disconnection of the breathing
circuit as the patients head was turned during a minor
nasal operation. This was immediately recognized by the
anaesthetist and corrected, but seemed to be regarded almost
as an expected occurrence in this context. Some of the
events we have classified as lack of smoothness may be
regarded as an integral part of anaesthetic practice, but
our classification deviation from protocol is based on
our interpretation of instances where national or local policies governing safe practice have been breached.
During the study period we observed two departmental
audit meetings and were also able to analyse the minutes of
the remaining 10 meetings. Twenty-eight cases and events
were discussed, of which 5 (18%) were presented as critical
incidents (Table 2).
We have found only one incident form completed during
the study period in the department records. This is not entirely clear, but seems to relate to difficulty estimating the
oxygen content in the gas mixture in the recently installed
new anaesthetic machines. This appears to relate to an incident discussed at an audit meeting (Table 2, incident xxiv).

The purposes of discussion and reporting

Our data also shed light on practitioners perceptions of
the purposes of discussing and reporting incidents. Critical
incidents were perceived by our interview respondents as
significant moments in the acquisition of their professional
expertise. When we asked them about how they had
acquired their anaesthetic knowledge, many focused, without prompting, on cases which had not gone according to
plan, which had either happened recently or during their
training. They seemed to have learned much from such
cases, even though there were usually only a small number
of them in each individuals career. Within the audit meetings we observed, the section where cases were presented
and events were discussed were usually of interest to all
present, and triggered lively discussion. This alludes to the
first reason for reporting, that is for continuing education
within the community of anaesthetists. This may be to alert
them to new problems, or simply to remind them of things
which are recognized complications of anaesthetic practice,
though not often seen.
Our respondents perceived that presenting and discussing adverse events could invite criticism and censure from
colleagues. The distinction was made between an incident
where a mistake might have been made, and one where an
unpredictable chance happening takes place. In this context
we report our observation of a case presentation at a departmental audit meeting. The anaesthetist involved, after commenting that it is still possible to be surprised after many
years in clinical practice, described how a previously fit
woman had become hypotensive after an abdominal operation. This had persisted despite i.v. fluid replacement and

717

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

anaesthetic practice. He goes on to say that this incident was

therefore not deemed critical.
The relevance of perception of control was echoed in
another of our interviews, where an SHO with 4 months
experience recounted a case from a recent weekend on call.
A previously fit 36-yr-old man had been listed for an
appendicectomy. During the preoperative visit, the SHO
had noted that the patient was pyrexial and clammy. The
patient tended to persistent tachycardia and hypotension
despite i.v. fluid replacement during the operation. He regurgitated gastric contents shortly after extubation of the trachea, became cyanosed and had to be re-intubated. Arterial
blood gas analysis confirmed a metabolic acidosis suggestive of systemic sepsis of some hours duration. The SHO had
considered this possibility intra-operatively but had not
quite put all the clues together. It was only when he felt
he had lost control of the situationspecifically, being
unable to manually ventilate the patients lungs in the recovery room after extubationthat the case became critical.
We also noted that, during an audit meeting early in our
study period, there was some discussion as to what incidents
satisfied the requirements for reporting on the clinical
incident reporting form. This was raised after discussion
of a difficult intubation where the patients trachea had
eventually been successfully intubated on the third attempt.
It was felt that as this had been anticipated, it did not
satisfy the criteria for reporting.
Practitioners used the term critical incident in another
sense, that is of an opportunity for learning or reflection
arising from practice. A consultant obstetric anaesthetist
recounted trying to first extend an existing epidural
block, then perform a spinal anaesthetic, then, when neither
of these proved effective, converting to a general anaesthetic
for Caesarian delivery of a woman in labour. An interview
with a senior ODP (see Supplementary data online for
Appendix 2) alluded to the fact that anaesthetists develop
expertise by discussing such cases, and also commented that
this very expertise makes them more skilled at recognizing
when things are going wrong. A recovery nurse brought with
her to her interview four written cases she termed critical
incidents. One involved a disagreement with a trainee
anaesthetist who refused to consider a patient controlled
analgesia (PCA) machine for an opioid addict, while another
related to the temporary holding of a critically ill patient in
the recovery room until a transfer to an intensive care unit in
another hospital could be arranged. It appeared that what
made these and the other incidents critical for her was the
perception that she was unable to influence doctors actions,
leading to a breakdown in working relationships which thus,
in her view, jeopardized patient safety.

Smith et al.

Table 1 Continued

Table 1 Classification of minor events observed

Category

Examples

Frequency

Lack of
smoothness
(n=25)

Physical
hazards
(n=6)

Examples

Frequency

No handover to recovery staff

Request to theatres to check space
available in recovery before transferring
patient ignored
Disconnection of breathing system
Anaesthetist tripped over cable

1
1

TIVA infusion lines stretched

Cables and i.v. lines badly tangled
I.V. cannula pulled out inadvertently

1
1
1

2
1

he had mistakenly attributed it to continuing occult intraabdominal bleeding. Only after a further laparotomy, where
no abnormality was found, did systemic sepsis suggest itself
as the cause of the hypotension. This event could be defined
as a critical incident using the RCA definition above but was
instead presented under the title A cautionary tale. As
such, it acknowledged tacitly that there had been an error
of judgement but the tone of the presentation suggested that
this could have happened to anyone. Discussing the case was
clearly of educational benefit to the other anaesthetists present, but there is no record of a written incident report for
this case.
Discussion and reporting seems also to have been complicated by the proliferation of schemes. One respondent perceived in particular that the two schemes in operation in the
hospital served different purposes and this appeared to influence the definitions used (see supplementary data for
Appendix 3).

Discussion
Anaesthetic practice has many potential hazards to patient
safety. Our data suggest that some of these are discussed and
lessons shared, though few are formally reported as critical
incidents. Further, although many minor events may be
reportable as near misses, or even constitute violations
of official safety notices, many do not seem even to be
acknowledged.
Despite the acknowledged importance of incident reporting, it is known that under-reporting is usual.12 13 This has
been attributed to design of forms,14 the belief that error can
be used as a measure of individual competence15 or unwillingness to report colleagues.16 Further, different schemes
may be perceived as having different, sometimes conflicting
purposes. The anaesthetist quoted in web Appendix 3 also
alluded to this when he distinguished between critical
incident reporting (as understood by anaesthetists) and
the recently introduced Trust incident reporting scheme
(termed clinical incident reporting) and now linked in
to the NPSAs National Reporting and Learning System,
with its potential for loss of control of the incident and
its interpretation. In particular, the potential for blame,
which may be more easily attributed by those from outside

718

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

6
Cough/hiccough/chomping
5
on induction
Low blood pressure
Inappropriate patient movement
5
during surgery
Low SpO2 on pulse oximeter
2
Residual neuromuscular block in recovery
2
ET tube inserted into right main bronchus
1
Attempted use of nerve locator in patient who
1
had been given neuromuscular blocking agents
Vaporizer turned on but no fresh gas flow
1
Slow to regain consciousness in recovery
1
Anaesthetic turned off too early
1
at end of operation
6
Venous cannulation
Procedural
5
difficulty/failure Laryngeal mask airway
2
Spinal anaesthesia
(n=18)
Arterial cannulation
2
Bag and mask ventilation
2
Tracheal intubation (medical student)
1
4
Deviation from Re-attachment of partially used i.v. fluid bag
No monitoring during some part of anaesthetic 3
protocol
(n=23)
Silencing monitor alarms
3
Confusion over consent/laterality/X-ray
3
Inappropriate handling of sharps
2
Anaesthetist left room briefly
2
No i.v. antibiotic given to patient having
1
total hip replacement
Anaesthetist eating crisps in scrub area
1
Anaesthetist declined use of fluid warmer
1
for expected long orthopaedic operation
Patient not visited before operation
1
Infection control policy breached
1
Local anaesthetic infusion nearly
1
connected to i.v. cannula
5
Equipment and Monitor alarmed when no problem
with patient
monitoring
(n=20)
ECG electrode falls off
2
Recovery staff unfamiliar with
2
operating infusion pump
Loose connection within
2
peripheral nerve locator
CO2 monitor not functioning
1
Ventilator tubing kinked
1
Propofol leaking from around
1
i.v. cannula (TIVA)
TCI pump battery exhausted
1
Air in TCI line
1
Breathing circuit incorrectly assembled
1
Difficulty establishing SpO2 trace
1
Rebreathing CO2
1
Shoulder surgery attachments did
1
not fit operating table
1
Organizational/ Order of operating list changed
1
Diabetic patient not established on
personnel
insulin as prescribed
(n=11)
Anaesthetist sedated patient without
1
informing other staff present
Premedication not given when prescribed
1
Anaesthetist misunderstood surgeon
1
Surgeons pulled patient down table
1
without first informing anaesthetist
Anaesthetist set propofol infusion running
1
without informing patient or other staff
Air pipeline disconnected by theatre staff
1
after being checked by anaesthetist
No anaesthetic assistant present on
1
emergenceabsent from theatre

Category

Adverse events in anaesthetic practice

Table 2 Incidents and cases discussed at audit meetings during 12 months of study. Those presented as critical incidents marked*

anaesthesia as they lack the contextual understanding of our

practice, appears to influence the decision to designate a
particular event as critical. This might be expected to discourage reporting through hospital-wide mechanisms, but a
decline has also been noted in reporting within one local
departmental scheme since the NPSA scheme was introduced.17 Thus, although discussion of events and cases
persistsincluding the sharing of positive experiences, in
line with Flanagans original critical incident technique18formal reporting is neglected.
Definitions of criticality within anaesthesia have largely
been taken at face value in reviews of the subject.19 20 In
the UK, the RCA definition is widely known and the NPSA
National Reporting and Learning Scheme definition is
similar.4 Other definitions vary20 but typically incorporate
elements of undesirability, preventability, severity and
include also the potential for harm and actual harm. Why
then are potential threats to patient safety, such as the

disconnection of the breathing circuit we observed, not

reported? We suggest that expertise in anaesthesia brings
with it not only knowledge and skill but also definitional
powerthe ability to set or impose a definition of the
situation as routine or critical.
We have previously argued that the ability to distinguish
the wide range of normal responses and conditions during
anaesthesia from abnormal is one of the hallmarks of
expert anaesthetic practice,6 and hence it is logical that it
also defines the threshold for criticality. We have reported
two similar cases of abdominal sepsis causing diagnostic
confusion. However, the trainees was reported as a critical
incident, but the consultants as a cautionary tale. Thus,
although the official definitions of criticality are apparently
clear, they are operationalized within a specific community of practice.21 Thus in Tamuz and colleagues22 study
of hospital pharmacy personnel in the United States, 23 how
errors were classified dictated how they were handled within

719

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

Preoperative
(i)
*Diabetic patient brought to theatre with insulin infusion running but no dextrose
(ii)
Asystole on inductionpatient undergoing laparotomy for peritonitis. Excellent preoperative resuscitation and preparation
(iii)
Intravascular injection of local anaesthetic during local block for carotid endarterectomydespite prior aspirationsuccessfully treated
(iv)
*Leaking thiopental syringe during rapid sequence induction for emergency Caesarian sectionleak in pre-prepared syringe made up in
Pharmacy department
(v)
Unexpected awkward intubation during rapid sequence induction for emergency laparotomy, resulting from undiagnosed laryngeal polypintubated with
4 mm microlaryngeal tube
(vi)
Difficult intubationeventually performed using fibreoptic laryngoscope through a laryngeal mask airway
(vii)
Difficult intubation in patient for thyroidectomy7 mm tracheal tube would not pass beyond vocal cords, though 6 tube would. Review of chest
radiograph revealed tracheal deviation, though not reported by radiologist
(viii)
*Diabetic patient with unstable glycaemic control for termination of pregnancy. Admitted to hospital the day before planned operation. Delay in adequate
glycaemic management because of the moral objections of trainee gynaecologists to procedure
Intraoperative
(ix)
Cardiac arrest after administration of i.v. protamine during aortic stenting. Patient successfully resuscitated. Consensus of meeting was that it was an
exaggerated normal response to drug
(x)
*Tracheal tube severed by surgeons osteotome during maxillary osteotomy
(xi)
Bradycardia during laparoscopy in patient with known latex allergyunrelated to allergy
(xii)
Small pneumothorax, leading rapidly to hypotension, electromechanical dissociation and asystole during thoracoscopic sympathectomy. Patient
resuscitated successfully
(xiii)
Anaphlyaxis to i.v. antibiotic during awake Caesarian section
(xiv)
Sustained low arterial blood pressure during revision of total hip replacementpatient developed postperative renal failure
(xv)
Low end-tidal CO2 and heart rate 170 beats min 1 during irrigation of amputation stump abscess with hydrogen peroxidethought to be air embolism.
Successfully treated
Postoperative
(xvi)
Two cases of postoperative respiratory depression on surgical wards because of opioids. One from patient-controlled analgesia, one from oral
morphine. Both appeared to be a result of enhanced sensitivity rather than absolute overdose
(xvii)
Bradycardia and cardiac arrest in the recovery room, thought to be attributable to myocardial ischaemia
(xviii)
Postoperative fits in epileptic patient who had received propofol and alfentanil for general anaesthesia. Postoperative questioning revealed she had
discontinued her usual phenytoin a few days before the procedure
(xix)
Recovery staff not informed on handover that a patients tooth was loose. Tooth fell out and was retrieved but staff felt it would have been better to
have been told in advance
(xx)
Horners syndrome noted after interscalene brachial plexus block (recognized complication of procedure)
(xxi)
Cardiac arrest after sedation for dental clearance. Postoperative investigation revealed a low serum potassium concentration. Patient was taking two
diuretics and should have had serum electrolytes checked before procedure
(xxii)
Sepsis during appendicectomy (see text)
(xxiii)
Negative pressure pulmonary oedema after emergency appendicectomythought to have occurred when patient was biting on, but trying to breathe
through, the tracheal tube before extubation
Miscellaneous
(xxiv)
*Oxygen analyser on anaesthetic machine in anaesthetic room read 17% when machine delivering at least 33%. Machine withdrawn from use until
repaired. No harm to patients
(xxv)
Cautionary talesepsis masquerading as intra-abdominal bleedingsee text
(xxvi)
Three cases of central venous line insertion discussed to show recommended tip position
(xxvii) Case reportuse of cell saver device to reduce transfusion requirements during emergency repair of ruptured abdominal aortic aneurysm
(xxviii) Brown fluid aspirated before local anaesthetic injection during lumbar sympathectomy. Ultrasound scan revealed 9 cm wide aortic aneurysm sac. No harm
resulted to patient; all patients now scanned before procedure performed

Smith et al.

The tremendous educational value of noteworthy events,

both in the development of trainees knowledge and in the
maintenance of collective wariness within the profession of
anaesthesia as whole, is widely recognized in anaesthesia.
In an era where evidence-based practice is favoured, it is
important to remember that the educational power of
narratives of individual cases. However, confusion over
how official definitions should be interpreted, mistrust
of newer reporting systems and the perception of loss of
control over incidents reported outside the anaesthetic
community, appear to have discouraged the formal documentation of incidents. Large-scale critical incident reporting schemes are destined to fail if they do not take these
professional issues into account.
Further, although the specialty of anaesthesia led the way
in systems thinking in healthcare safety through the
collection and analysis of critical incidents, there appears
to be room for further improvement. Within other safetycritical industries, such individual interpretation of official
directives such as the re-pressurizing of i.v. fluids we
observed would be unacceptable. To us, this is the paradox
of anaesthetic expertise. On the one hand it brings the ability
to recognize and react flexibly to (sometimes previously
unknown) threats to patient safety, but on the other it
also militates against the adoption of highly standardized
operating procedures as in other industries. Full adoption of
the industrial paradigm of patient safety would imply an
end to the exercising of such professional discretion in
most routine practice conditions.
Further research in this area could usefully define the
limits, if any, of transferability of such principles into
anaesthesia.30 It would be useful, too, to explore more
systematically, perhaps through scenario-based work,
differences in classification with experience. A clearer
understanding of the significance of minor events would
also be of interest. Lastly, given the confusion over what
is reportable in anaesthesia, it is reasonable to ask if incident schemes in high-risk areas need to be different in
some way from those in clinical areas where there may
be less potential for error.

Supplementary data
The appendices can be found as supplementary data in
British Journal of Anaesthesia online.

Acknowledgement
Funding: NHS North West Regional R&D Fund Project no RDO 28/3/05.

References

720

1 Barach P, Small SD. Reporting and preventing medical mishaps:

lessons from non-medical near miss reporting systems. Br Med J
2000; 320: 75963
2 www.rcoa.ac.uk (Accessed July 1, 2005)
3 Department of Health. Building a Safer NHS for Patients. London:
The Stationery Office, 2001

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

the hospital organization. In Barach and Smalls1 survey

of reporting system experts, there was agreement on the
importance of accepted definitions, but the problem of interpretation in practice was not addressed. Whilst, in theory
at least, broad, ambiguous definitions of potential dangers
might aid the discovery of risks that escape existing
definitions,24 this has not been borne out by experience in
other industries.
Our observational data captured many minor events
which may not in themselves be significant. However,
Boelle and colleagues25 demonstrated an association
between undesirable events in anaesthesia (not in themselves harmful) and subsequent critical outcome events. If
this relationship is robust, events hitherto judged too trivial
to scrutinize may be worthy of closer analysis.26 We would
not, however, advocate formal reporting of such events
until their proper role is established, though they may be
useful in internal departmental quality control.
We also witnessed anaesthetists intentionally deviating
from protocol. For instance, re-connecting partially used
bags of i.v. fluid is in direct contravention of a UK Medical
Devices Agency Hazard Notice27 of which at least some
of the anaesthetists we studied were certainly aware. The
Notice was issued after two patients died from air embolism
when reconnected bags were pressurized for rapid infusion.
What our anaesthetists did not do was pressurize the bags.
We suggest that they felt that their knowledge of the
circumstances of the fatal incidents prevented them from
repeating them. In doing so, they exercised their expert
judgement to keep things safe but this could still be construed as a violation of defensible practice. It is of note,
however, that the arbiter of standards, the Medical Devices
Agency, falls outside the anaesthetic community of practice. In this context, we note the findings of Beatty and
Beatty,28 whose scenario-based study suggested that anaesthetists intentions to violate safety guidelines are most
strongly influenced by the opinion, they believe, a group
of peers and significant other people would hold about the
violation. We interpret this as support for our notion that
expertise in anaesthesia brings with it the authority to define
the boundaries between routine and critical but also between
acceptable and unacceptable practice. However, we suggest
that such variability in what is considered critical, reportable and acceptable is a product of the culture of medicine.
In other safety-critical industries, professional experience
and judgement are not allowed to dictate reporting behaviour. In aviation, for instance, all pilots, regardless of rank
or experience, are expected and required to describe and
report even the most subtle and minor events, not just
those deemed critical or serious by individual pilots.
Such attitudes to open discussion of error and potential
error are intentionally fostered by the behavioural strategies
of crew resource management training.29 In medicine, on
the other hand, susceptibility to error is not universally
acknowledged by medical staff and error is often not
handled appropriately.5

Adverse events in anaesthetic practice

721

19 Davies J. Critical incident reporting in anaesthesia. In:

Healy TE, Cohen PJ, eds. Wylie and Churchill-Davidsons
A Practice of Anaesthesia, 6th Edn. London: Edward Arnold,
1995: 92437
20 Derrington C. Critical incidents in anaesthesia. In: Secker
Walker J, ed. Quality and Safety in Anaesthesia. London: BMJ
Books, 1994: 10528
21 Wenger E. Communities of Practice: Learning, Meaning, and Identity.
Cambridge: Cambridge University Press, 1998
22 Tamuz M, Thomas EJ, Franchois KE. Defining and classifying
medical error: lessons for patient safety reporting systems.
Qual Saf Health Care 2004; 13: 1320
23 Sutcliffe KM. Defining and classifying medical error: lessons for
learning. Qual Saf Health Care 2004; 13: 89
24 Tamuz M. Developing organisational safety information systems
for monitoring potential dangers. In: Apostolokis GE, Wu JS,
eds. Proceedings of Physical Sciences Annual Meeting II. San Diego,
CA: Galen Press, 1994: 712
25 Boelle P-Y, Garnerin P, Sicard J-F, Clergue F, Bonnet F. Voluntary
reporting system in anaesthesia: is there a link between
undesirable and critical events? Qual Health Care 2000; 9: 2039
26 Smith AF, Goodwin D, Mort M, Pope C. Categorisation and
significance of non-conformities in anaesthetic practice:
pointers from the Lancaster anaesthetic expertise study.
Br J Anaesth 2005; 94: 405P
27 Medical Devices Agency Hazard Notice HN 9702, 1997. Available from
www.smtl.co.uk/Documents/Newsletters/Volume1-Issue1-Oct-1997
28 Beatty PCW, Beatty SF. Anaesthetists intentions to violate
safety guidelines. Anaesthesia 2004; 59: 52840
29 Helmreich RL. On error management: lessons from aviation.
Br Med J 2000; 320: 7815
30 Van der Schaaf TW. Medical applications of industrial safety
science. Qual Saf Health Care 2002; 11: 2056

Downloaded from http://bja.oxfordjournals.org/ by guest on August 14, 2016

4 www.npsa.nhs.uk (Accessed July 1, 2005)

5 Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork
in medicine and aviation: cross sectional surveys. Br Med J 2000;
320: 7459
6 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice:
an ethnographic study exploring the acquisition and use of
knowledge in anaesthesia. Br J Anaesth 2003; 91: 31928
7 Hammersley M, Atkinson P. Ethnography. Principles in Practice, 2nd
Edn. London: Routledge, 1998; 13
8 Savage J. Ethnography and health care. Br Med J 2000; 321: 14002
9 Merry AF, Davies JM, Maltby JR. Qualitative research in health
care. Br J Anaesth 2000; 84: 5525
10 Pope C, Ziebland S, Mays N. Analysing qualitative data. Br Med J
2000; 320: 11416
11 Hammersley P. Reading Ethnographic Research: A Critical Guide.
Harlow: Longman, 1990; 117
12 Leape LL. Error in medicine. JAMA 1994; 272: 11517
13 Stanhope N, Crowley-Murphy M, Vincent C, OConnor AM,
Taylor-Adams SE. An evaluation of adverse incident reporting.
J Eval Clin Pract 1999; 5: 512
14 Johnson CJ. Designing forms to support the elicitation of information about incidents involving human error. Proceedings of the
19th European Annual Conference on Human Decision Making
and Manual Control 2000; 12734. Available from www.dcs.gla.
ac.uk/~johnson/papers/incident_forms/
15 Cohen MR. Why error reporting systems should be voluntary.
Br Med J 2000; 320: 7289
16 Lawton R, Parker D. Barriers to incident reporting in a healthcare
system. Qual Saf Health Care 2002; 11: 1518
17 James RH. 1000 anaesthetic incidents: experience to date.
Anaesthesia 2003; 58: 85663
18 Flanagan JC. The critical incident technique. Psychol Bull 1954; 51:
32758