1. RELATION TO INCIDENT

1.1 Who is reporting ?
... MD-anaesthetist; non-Resident MD-anaesthetist; Resident anaesthetic Nurse Surgical Nurse, Technician other Technician MD-Surgeon; non-Resident MD-Surgeon; Resident (select the most appropriate field)

1.2 How were you related to this incident ?:
... primary provider of anaesthetic care helping the primary provider observing and responsible for care observing, not responsible (select the most appropriate field)

1.3 Team members ...
... present during occurance of the incident (check all appropriate fields)

... experience and workload of the primary provider of anaesthetic care

years practicing anaesthesia
hours on duty without sufficient rest

2. PATIENT DATA

2.1 Sex male female

2.2 Age years

2.3 Hospitalization In-Patient Out-Patient admit day of procedure / same day admission

2.4 Type of procedure Elective case Emergency during day Emergency during night Emergency on the weekend during day

2.5 ASA status class I class II class III class IV class V

2.6 Preexisting morbidity (check all appropriate fields)

2.7 Conditions (check all appropriate fields)
trauma patient
multiple trauma patient
disease
pregnant patient
NPO (nothing p.o.) < 6 hours

2.8 Type of surgery
... neurosurgery / brain neurosurgery / spinal cord eye surgery ear-nose-throat surgery orofacial / neck surgery cardiac surgery thoracic surgery vascular surgery abdominal & genitourinary surgery orthopedic bone & joint surgery orthopedic spine surgery obstetric procedure gynecologic surgery breast, skin & misc. surgery diagn. & non-surg. intervention resuscitation (select the most appropriate field)

select: minor intervention major intervention

3. ANAESTHESIA DATA

3.1 Anaesthesia technique
... general anaesthesia regional anaesthesia combined general / region. anaesthesia monitored anaesthesia care regional block for chronic pain resuscitation (select the most appropriate field)

3.2 Airway-management (check all appropriate fields)

3.3 Agents in use (check all appropriate fields)

other :

3.4 Regional anaesthesia
Drug application
single shot continuous repeated bolus
Vertebral column: (check all appropriate fields)

Upper extremity: (check all appropriate fields)
Plexus block arm
Lower extremity:
Plexus block leg
Miscellaneous:

3.5 Monitoring (check all appropriate fields)

Machine:

Patient:

other,please specify:

4. INCIDENT DATA

4.1. Where did the incident happen
... induction room OR recovery room ICU general ward emergency ward obstetric unit psychiatry unit radiology suite during in-hospital transport out of the hospital (helicopter, ambulance...) (select the most appropriate field)

4.2 When did the incident happen
... before induction during induction during maintenance during emergence during recovery same day post OP (select the most appropriate field)

4.3 When was the problem recognized
immediate delayed

4.4 What happened

General type of event Complication Critical incident [Definition]
(Please check one. For combined incidents please report twice)

Airway event	... acute upper airway obstruction laryngospasm inability to ventilate inability to intubate esophageal intubation unexpected difficult airway endobronchial intubation tracheal tube cuff herniation disconnection of ventilator tubings completely obstructed tracheal tube soft tissue airway trauma after laryngoscopy vocal cord paresis airway burn accidental extubation other airway problem
Pulmonary event	... hypoxemia hypercapnia bronchospasm aspiration of gastric content pulmonary edema post laryngospasm pulmonary edema pneumothorax tension-pneumothorax atelectasis mediastinal emphysema pulmonary thromboembolism pulmonary hemorrhage other pulmonary problem
Cardiac event	... hypotension req. intervention hypertension req. intervention hypovolemia suparaventr.arrhythmia ventr.arrhythmia atrial fibrillation bradycardia req. intervention tachycardia req. intervention pacemaker dysfunction pacemaker failure myocardial ischemia/infarction cardiac failure cardiac arrest other cardiac problem
Regional anaesthesia event	... failed regional anaesthesia wet tap (epidural) total spinal too high a block level during spinal/epidural severe hypotension during spinal/epidural systemic toxicity of local an. drug systemic tox. of adjuvant large hematoma during RA pneumothorax after RA subarachnoid spread during cervical block accidental epidural spread during cervical block lesion of a plexus lesion of a nerve lesion of the bulbus other RA problem
Cannulation event	... pneumothorax tension-pneumothorax hemothorax accidental punction of artery pericardial tamponade dissection of vessel large hematoma lesion of plexus or nerve arrhythmia req. treatment during PA-cath. placement pseudoaneurysm of the pulmonary artery after PA-catheter thrombosis of end-artery after can. or attempt av-fistula after arterial can. or attempt shear off of catheter acc. subcutaneous infusion other cannulation problem
Equipment event	... circuit leak sticking valves (circuit) exhausted soda lime vaporizer-empty vaporizer-malfunction ventilator-failure accidental PEEP comp. fail. of bag and mask system comp. fail. of laryngoscope comp. fail. of suction device comp. fail. of pressure-transducer comp. fail. of pacemaker oxygen supply-problems N2O supply-problems electrical power failure other equipment problem
Monitoring event	... failure of ... - capnography/capnometry ... - pulse oximetry ... - ECG ... - blood pressure, non-invasive ... - blood pressure, invasive ... - stethoscope, esophageal ... - stethoscope, precordial ... - stethoscope, paratracheal ... - central venous pressure (CVP) ... - pulmonary artery (Swan-Ganz) catheter ... - transesophageal echocardiogram ... - peripheral nerve stimulator ... - temperature probe other monitoring problem
Positioning event	... pressure sore other cutaneous lesion burn joint dislocation fracture drop of patient eye injury peripheral nerve damage plexus damage muscle damage (compartment syndrome) vessel obstruction other positioning problem
Miscellaneous event	... hypothermia hyperthermia MH-crisis awareness central anticholinergic syndrome porphyric crisis allergic reaction to latex other
Communication event	... overtired conditions unnecessarily stressful conditions workload too heavy during stressful condition poor communication / coordination exemplary communication / coordination no briefing exemplary briefing no debriefing exemplary debriefing poor teambuilding exemplary teambuilding (For an introduction in the topic of team performance and examples please click here)
Pharmacologic event	... wrong drug wrong dose wrong concentration of drug wrong labeling wrong site of injection drug interaction drug side effect adverse drug effect local allergic reaction systemic allergic reaction paradoxical reaction necessary drug not available at site cholinesterase deficiency other pharmacologic problem

Wrong drug ..:
Intended drug:
Interaction between drug I:
and drug II:

4.6 Please give a description of this incident in your own words (we would like you to be careful not to present data here, that could identify the patient, the team or the institution):

4.7 Which monitor led to the detection of the incident ?
Best monitor: ... clinical observation laboratory value Airway pressure alarm Oxygen analyzer Capnography / Capnometry Pulseoximetry Blood pressure (intra-arterial) Blood pressure (non-invasive) ECG Stethoscope peripheral nerve-stimulator Temperature patient precordial Doppler Mass-Spectrometer (inhal.agents) N2O-Detection Transesophageal Echocardiography (select the most appropriate field)
2nd best monitor: ... clinical observation laboratory value Airway pressure alarm Oxygen analyzer Capnography / Capnometry Pulseoximetry Blood pressure (intra-arterial) Blood pressure (non-invasive) ECG Stethoscope peripheral nerve-stimulator Temperature patient precordial Doppler Mass-Spectrometer (inhal.agents) N2O-Detection Transesophageal Echocardiography (select the most appropriate field)

4.8 What drugs did you use for the management of the incident / resuscitation ? (free text)
1. drug :
2. drug :
3. drug :

4.9 What was your clinical strategy for management ? (check all appropriate fields)

4.10 Please describe your management:

5. OUTCOME AND ESTIMATION

5.0 Severity
If this CI had progressed, what might the realistic outcome have been ?
(For help to this topic, simply click on: severity-score)

... transient abnormality unaware to the patient transient damage with complete recovery potentially permanet morbidity potentially disabling morbidity death (select the most appropriate field)

5.1 Outcome (if you already know)
... Outcome not affected by incident Patient dissatisfaction Prolonged hospitalisation Unplanned hospitalisation of an out-patient Unplanned ICU-admission Minor morbidity Major morbidity Death (select the most appropriate field)

5.2 Circumstances of the incident
In this section a score from 1 to 5 (Likert score) follows. Every question with a score should be answered. Please insert any number between 1 and 5.

Circumstances: Personal factors

question	score (1 - 5)
no sleep in the past 24 h (score 1)... more than 7 h of sleep in the past 24 h (score 5)
serious job stress (1)... no job stress (5)
serious nonjob-related stress (1)... no nonjob-related stress (5)
workload unusually heavy (1)... workload unusually light (5)
ill staff (1)... healthy and strong staff (5)
inadequate knowledge of situation (1)... extensive understanding of all included factors (5)
no appropriate skills (1)... very strong skills (5)
no appropriate experience (1)... extensive experience (5)

check all appropriate fields:

no check of patient	no check of drugs
no check of equipment	no permit (although required)
not qualified	wrong planing of procedure

Circumstances: Team factors, communication

Likert scale! Please answer every question. Insert any number between 1 and 5.

question	score (1 - 5)
no briefing (1)... pertinent and thorough briefing (5)
no teambuilding (1)... exemplary teambuilding (5)
no debriefing (1)... exemplary debriefing (5)
major communicational/coordinational breakdown (1) ... efficient comm./coord. (5) ... in the anaesthetic team
major communicational/coordinational breakdown (1) ... efficient comm./coord. (5) ... in the surgical team
major communicational/coordinational breakdown (1) ... efficient comm./coord. (5) ... between both teams
poorly staffed (1)...fully staffed (5)

Circumstances: Equipment
(check all appropriate fields)

poor design of the equipment	poor construction
poor maintenance of the equipment (replacement, repair)	lack of equipment
poor workplace design	technical failure
wrong drug labelling	misleading arrangement of drugs

Circumstances: System (management and environment)

Likert scale! Please answer every question. Insert any number between 1 and 5.

question	score (1 - 5)
unfamiliar surrounding (1)... complete familiar surrounding (daily workplace) (5)
bad working conditions (1)... exemplary working conditions (5)
inappropriate help (1)... exemplary help/support (5)
no adherence to algorithms, rules, procedures (1)... consistent adherence to algorithms, rules, procedures (5)
no monitoring (1)... appropriate monitoring (5)

5.3 Recoveries (check all appropriate fields)

Recoveries: Personal factors

appropriate knowledge	skill
experience	situational awareness

Recoveries: Team, communication

appropriate communication/coordination in the anaesthetic team

appropriate communication/coordination in the surgical team

appropriate communication/coordination betwean both teams

appropriate briefing

appropriate teambuilding

Recoveries: Equipment

additional monitoring	replaced monitoring
additional drugs	replaced drugs
additional equipment	replaced equipment

Recoveries: System (mangement and environment)

additional personel	replaced personel
use of appropriate algorithms, rules, procedures	repeated check
additional knowledge (experienced support)

5.4 What would you suggest for prevention of this incident ? (check all appropriate fields)

5.5 In your opinion:
the incident was preventable
the incident was not preventable

the incident belongs to the following error-category (more than one category can be involved!!)
(For help to this topic, simply click on: error-category)
patients condition
personell factors (incl. human error)
environment/equipment (incl. technical failure)
organisation (ie, the hospital)
regulatory (government cut-backs, rules ...)

if you completed all fields, then click on

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