1. RELATION TO INCIDENT

1.1 Who is reporting ?
... MD-Anesthetist; non-Resident MD-Anesthetist; Resident Anesthetic 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 anesthetic 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)

MD-Anesthetist, non-Resident	Second MD-Anesthetist, non-Resident
MD-Anesthetist, Resident	Second MD-Anesthetist, Resident
Anesthetic Nurse	Second Anesthetic Nurse
Surgical Nurse / Technician	Other Technician
MD-Surgeon, non-Resident	MD-Surgeon, Resident

Experience and workload of the primary provider of anesthetic care
years practicing anaesthesia
If licensed years after licensing / certification
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)

heart	lung
CNS	kidney
gastro-intestinal	liver
multi-system disease

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)

mask	laryngeal mask (LMA)
orotracheal intubation	nasotracheal intubation
tracheostomy	cricothyrotomy
jet-ventilation

3.3 Agents in use (check all appropriate fields)

Inhalational Drug	iv-anesthetic drug
Opiate	non-depol. musclerelaxant
Succinylcholine / Suxamethonium

other :

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

Spinal

Epidural

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

Intravenous-block (Bier)	Peri-retrobulbar block
Intercostal nerve block	Interpleural catheter anaesthesia

3.5 Monitoring (check all appropriate fields)

Machine:

Airway pressure alarm	Oxygen-Analyzer
Expired volume alarm	Nitrous Oxide (N2O)-Analyzer
Mass-Spectrometer inhal.agents

Patient:

ECG	Blood pressure, non-invasive
Pulse oximetry	Capnography
Blood pressure, intra-arterial	Stethoscope
Peripheral nerve-stimulator	Temperature, patient
Doppler, precordial	Swan-Ganz PA-catheter
Transesophageal echocardiography

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

Drug involved:
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)

stop operation	stop anaesthesia
modify operation	modify anaesthesia
managed using standard protocols	managed using own protocol

4.10 Please describe your management:

5. OUTCOME AND ESTIMATION

5.0 Potential Severity
... 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 What led to the incident ? (check all appropriate fields)

Most important cause (check all appropriate fields)
personal factors
... fatigue haste illness of provider lack of knowledge lack of skill (technical) lack of experience lack of judgement poor situational awareness heavy workload poor task prioritization failure to check patient failure to check drugs failure to check equipment
team factors
... no briefing poor teambuilding no debriefing poor anaesthesia team communication/coordination poor surgical team communication/coordination poor communication/coordination between surgical and anesth. teams relief of the team
equipment
... wrong drug labeling unfamiliar drugs misleading arrangement of drugs lack of equipment/monitoring unfamiliar equipment/monitoring misleading equipment/monitoring misleading arrangement of equipment/monitoring technical failure
environment
... unfamiliar surrounding bad working conditions inappropriate help/support no help/support patient condition
administration
... wrong pre-op therapy wrong pre-op patient status judgement wrong planing of the anaesthesia

Second important cause, that led to the incident (check all appropriate fields)
personal factors
... fatigue haste illness of provider lack of knowledge lack of skill (technical) lack of experience lack of judgement poor situational awareness heavy workload poor task prioritization failure to check patient failure to check drugs failure to check equipment
team factors
... no briefing poor teambuilding no debriefing poor anaesthesia team communication/coordination poor surgical team communication/coordination poor communication/coordination between surgical and anesth. teams relief of the team
equipment
... wrong drug labeling unfamiliar drugs misleading arrangement of drugs lack of equipment/monitoring unfamiliar equipment/monitoring misleading equipment/monitoring misleading arrangement of equipment/monitoring technical failure
environment
... unfamiliar surrounding bad working conditions inappropriate help/support no help/support patient condition
administration
... wrong pre-op therapy wrong pre-op patient status judgement wrong planing of the anaesthesia

5.3 What minimized the degree of the damage ? (check all appropriate fields)
exemplary communication/coordination in the anesth. team
exemplary communication/coordination in the surgical team
exemplary communication/coordination between surgical and anesth. team

exemplary briefing	exemplary debriefing
exemplary teambuilding	monitoring
experience	vigilance
repeated check	relief of the team
experienced help/support	existence of appropriate algorithms

5.4 What worsened the degree of the damage ? (check all appropriate fields)
poor communication/coordination in the anesth. team
poor communication/coordination in the surgical team
poor communication/coordination between surgical and anesth. team

poor/no briefing	poor/no debriefing
poor/no teambuilding	poor/no monitoring
failure to check	impaired vigilance
fatigue	haste
illness	poor situational awareness
heavy workload	poor task prioritization
lack of experience	poor judgement
no relief of the team	no experienced help/support
no existance of appropriate algorithms

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

additional monitoring/equipment	improved monitoring/equipment
better maintenance of existing monitoring/equipment	improved arrangement of drugs
improved arrangement of monitoring/equipment	better training/education
better working conditions	better organization
better supervision	more personnel
better communication	more discipline with existing checklists
better quality assurance	development of algorithms / guidelines
abandonment of old 'routine'

5.6 In your opinion:
the incident was preventable
the incident was not preventable
the incident originated from a ... ... chance management error system error technical error human error
if you selected human error, please specify: ... slip / blunder knowledge based error rule based error skill based error

if you completed all fields, then click on

Only a joint effort of colleagues like Jan Davies (University of Calgary), Bob Helmreich (NASA, University of Texas), Mark Kaufmann (University of Basel), Bryan Sexton (Nasa, University of Texas), Brett Arron (University of Chicago) and many others ... made this system possible, thanks to everybody.
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Sven Staender