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Incident No:

A.I.M.S
ANAESTHETIC INCIDENT REPORT
You are invited to complete this report if an incident occurs
during your clinical practice.

DEFINITION Report any incident, no matter how seemingly trivial, which

affects or could affect the safety of the patient. The incident
may be preventable or unpreventable.

ANONYMITY The identity of the reporter and the patient do not appear on
this report. The only person who knows this information is you.

Write simply in your own words a description of what

INSTRUCTIONS
happened.Print the completed report and submit to our
Department Secretary.

MEDICO-LEGAL If you have ANY concerns about the medico-legal implications

of reporting this incident, DO NOT complete this report.

A nominated anaesthetist in your organisation is your local

COORDINATOR coordinator. Please feel free to discuss with himlher any incident
or any difficulties which you may encounter with this study.

It is NOT necessary to be more specific about the date, place

DETAIL
or procedure than is required by this form. Please complete all
sections so that your data will be more valuable. Note the report
number at the top of this page.

Modified from the A.I.M.S of Australian Patient Safety Foundation Inc. Created by Jimmy Phoo
June 1994 Version 5. 25/4/2011
ITEM 1: DESCRIPTION OF INCIDENT
In your own words describe the incident. Include details about any factors which you believe may have contributed to, or
minimized the incident. Note any measures which might be employed in the future to prevent any such incident. Of
particular interest are the following:
(1) Monitors in use at the time, and whether or not it was a monitor which first alerted you to the existence of a problem.
(2) Drug identification problems.

Multiple Incident? Yes No

NB: If more than one separate incident occurred (“multiple incident”) please fill out a separate report for each incident.

75 yr old Chinese Male

Premorbidly ADLs independent
PMHx
1. HTN
2. Mediastinal mass - s/p Sx in Gleneagles in 1997

Current Admission- 21/1/12 at 0721 hrs

Hx taken from son ( A & E notes )
P/w difficulty in breathing since morning
Noticed increasing neck mass since 7/12, seen by GP for the same- told to be Euthyroid based on blood investigations.
O/E
GCS 15
Pulse 123bpm, BP 157/69 mmHg, RR 24 bpm, Temp 36.5, SpO2 90% on RA
Plethoric, in respiratory distress
Stridor +++
Dilated neck veins
Large neck swelling
Heart : S1 S2
Lungs : Stridorous, diminished air entry into left lung
Abdomen : soft, non tender
ECG : sinus tachycardia
CXR : prev sternotomy wires seen , Heart appears to be large with prominent right border, large area of consolidation in left
lung, cystic changes in left lung bases, widening of the superior mediastinum. Right lung appears to be clear.

In A & E, Patient desaturated to SpO2 80% on 100% NRM , BVM to 100%

Given IV Etomidate 10 mg, Suxamethonium 100mg
Intubation attempted by A & E consultant with Glidescope, but unable to advance ETT ( # 7.5 ) beyond the vocal cords into
trachea.
ENT on call referred STAT
Seen by ENT reg on call 0810 hrs: Acute respiratory distress secondary to Goitre / Superior mediastinal mass
Plan : To EOT for awake FOB intubation kiv emergency tracheostomy
Admit to SICU for further management
In EOT -0815 hrs
ENT surgeon scrubbed up, ready for emergency surgical airway
Airway topicalised with LA
Larynx and trachea examined under direct fibreoptic bronchoscopy - noted glottic opening edematous ++ and narrowed,
minimal bleeding, subglottic extrinsic compression noted with severe compromise in tracheal diameter.
#7.0 ETT railroaded with difficulty through FOB. Capnography wave form confirmed. ETT secured 21 cm at lips & patient
sent to SICU for ventilatory support and further management.
CT Neck & Thorax (0900hrs):
-tip of the ETT within the upper trachea.
-large insinuating complex mixed fat/soft tissue mass involving the upper mediastinum as well as base of neck, severely
narrowing the upper mediastinal trachea which measures 5mm in calibre.
Do-there
you isthink this, incident
a separate was
similar but less preventable?
transpatial
Yes No Undecided
mass arising from the left mediastinum extending into the left
hemithorax causing mild surrounding mass effect.
Differential considerations of these findings include teratoma/ liposarcoma.
ITEM 2: KEYWORDS (to be completed by coordinator)
TFT & serial CE normal, FiO2 decreased to 40% based on normal ABGs
S/T son regarding tracing previous surgical records, but son said they have discarded all previous medical records and last
TCU was in 2000. Tried to obtain the records from medical records office at Gleneagles and NUH but none were available as
the patient had defaulted f/u for many years.
21/1/12 at1330 hrs: ENT team referred SGH CTVS consultant on call
Opinion from CTVS consultant after reviewing the scans :Mass may be stuck to the the adjacent structures including the
-thyroid
ITEM 3: WHAT HAPPENED?
CIRCUITRY INCIDENT
Dilution of gases (DL)
Disconnection (DI)
Leak (LE)
Misconnection (MI)
Overpressure (OV)
Rebreathing (RE)
Other circuitry incident (OT)
Specify: from airway
Nil (NI)
CIRCUITRY INVOLVED
Absorber (AB)
Common gas outlet (CG)
ETT or equivalent (ET)
Flowmeter (FL)
Gas supply (GS)
Humidifier (HU)
Oxygen bypass (OX)
Patient circuit valve (PC)
Pressure relief valve (PV)
Scavenging system (SC)
Tubing or connection (TU)
Vaporiser (VA)
Ventilator (VE)
Other circuitry involved (OT)
Specify:
Nil (NI)
ITEM 4: WHY IT HAPPENED
Factors contributing to incident
Communication problem (CP)
Distraction (DI)
Drug Label (DL)
Error of judgment (EJ)
Failure to check equipment (FC)
Fatigue (FA)
Fault of technique (FT)
Haste (HA)
Inadequate assistance (IA)
Inattention (IN)
Inexperience (IX)
EQUIPMENT INVOLVED PHARMACOLOGICAL INCIDENT
Airway (AW) Allergy phenomenon (AL)
Airway pack (AP) Contamination (CT)
Diathermy (DI) Inappropriate drug (IP)
Equipment malfunction (EM) Interaction (IN)
Infusion apparatus (IF) Overdosage (OV)
Intubation aid (IA) Side effect (SE)
Laryngoscope (LS) Wrong drug (WD)
Monitoring equipment (MO) Underdosage (UN)
Nasogastric tube (NG) Other drug incident (OT)
Needle/cannula (NC)
Specify:
Straps/tape (ST)
Nil (NI)
Syringe (SY)
Suction apparatus (SU)
Table/trolley/patient support
(TA) AIRWAY INCIDENT
Other equipment (OT) Difficult intubation (DI)
Endobronchial intubation (EB)
Specify:
Extubation (EX)
Nil (NI)
Failed intubation (FI)
Non-ventilation (NV)
Obstruction (incl. vomit/spasm)
(OB)
Oesophageal intubation (OI)
Trauma (TR)
Other airway incident (OT)
Specify:
Nil (NI)
Surgical team contribution (SC)
Lack of facility (LF) Unfamiliar environment or
Lack of monitor (LM) equipment (UN)
Monitor problem (MP) Other equipment problem (OE)
Inadequate/incorrect pre-op
patient assessment (PA) Specify:
Inadequate/incorrect pre-op Other stress (ST)
patient preparation (PP)
Specify:
Pressure to proceed (PS)
Relief of anaesthetist or staff Other factor (OT)
change (RA)
Specify:
Sick anaesthetist (SA)
Sick patient (SP) Nil (NI)
FACTORS MINIMIZING INCIDENT
Monitor detection (MD)
Specify which monitor first
alerted the problem (one only):
Healthy patient (HP)
High awareness via QA activity
(QA)
Prior experience/training (EX)
Re-check of equipment (RE)
Relief of anaesthetist or staff
change (RA)
Skilled assistance (SA)
Supervision (SU)
ITEM 5: ANAESTHESIA AND PROCEDURE
PROCEDURE CATEGORY
Cardiothoracic (CA)
Cardioversion (CV)
Dental (DE)
Diagnositic (inclu imaging/
biopsy) (DI)
Electroconvulsive therapy (EC)
Endoscopic (EN)
ENT (EN)
General surgical (GE)
Gynaecological (GY)
Haematological (HE)
Major multi-disciplinary (MM)
Maxillo-facial (MF)
Neurosurgical (NS)
Obstetric (OB)
Oncological (ON)
Ophthalmological (OP)
Orthopaedic (OR)
Plastic/reconstructive (PL)
Radiotherapy (RA)
Urological (UR)
Vascular (VA)
Others (OT)
Specify:
ELECTIVE ADMISSION:
Yes No
Other factor (OT) Fatigue alleviation routine (FA)
Improved communication (IC)
Specify:
Improved environment (IE)
Nil (NI) Improved supervision (IS)
More manpower (MM)
SUGGESTED CORRECTIVE Quality assurance activity (QA)
STRATEGIES Specify (eg AIMS, M&M, etc):
Additional equipment (AD)
Additional monitor (AM)
Additional training (AT) Specific protocol development
(SP)
Equipment checking discipline
(EC) Other strategy (OT). Specify:
Equipment design
improvement (ED)
Equipment maintenance Nil (NI)
discipline (EM)
ANAESTHESIA Other gas analyser (GA)
(You may choose more than one)
Oximeter (OX)
General anaesthesia (GA)
Oxygen analyser (OA)
Infiltration (IN)
Plethysmography (PL)
Regional/nerve block (RB)
Peripheral nerve stimulator (NS)
Sedation (SE)
Pulm arterial/wedge pressure (PA)
Nil (NI)
Automated NIBP (AU)
TYPE OF VENTILATION Manual NIBP (SP)
Spontaneous (SP) Spirometer (SR)
IPPV (IP) Stethoscope(preacordial/
Nil (NI) oesophageal) (ST)
Temperature (TP)
MONITORS IN USE Other monitor (OT)
Airway pressure gauge (AP)
Specify:
Airway temperature (AT)
Nil
Auto-disconnect alarm (AD)
Manual disconnect alarm (DA)
Capnograph
Cardiac output (CO)
Central venous pressure (CV)
Doppler praecordial (DO)
ETT cuff pressure (EP)
Electrocardiograph (EC)
Electroencephalograph/BIS (EE)
Intra-arterial pressure (IA)
Intracranial pressure (IC)
Mass spectrometer (MA)
N2O analyser (NO)
 ITEM 6: WHEN AND WHERE IT HAPPENED
LOCATION
Time: 0230 hrs
A&E (CA) Operating room (OR)
Date: Jan 24, 2012 Day surgery (DA) Other (in hospital). (OI) Specify:
Delivery room (DR)
PHASE WHEN ALERTED
Dental room (DE)
Pre-induction (PI) Other (out of hospital). (OO)
General ward (GE) Specify:
Induction (IN)
Radiology (IM)
Maintenance (MA)
In transit (TR)
Emergence (EM) Recovery
Induction room (IR)
Recovery (RE)
Intensive care (IC)
Post-recovery/ward (PR)

ITEM 7: TO WHOM IT HAPPENED

PATIENT AGE GROUP PATIENT ASA CLASSIFICATION EMERGENCY
Less than 1 year (IN) 1 2 3 4 5 6 Yes No
1 to 14 years (CH)
Greater than 14 years (AD)

ITEM 8: PATIENT OUTCOME

DURATION OF INCIDENT IMMEDIATE EFFECTS FINAL OUTCOME
Transient (<5 min) (TR) Cardiac arrest (CA) Awareness (AW)
Prolonged (>5 min) (PR) Major physiological change (MA) Death (DE)
Minor physiological change (MI) Major morbidity (MA)
Physical injury (PI) Minor morbidity (MI)
Nil (NI) Prolonged stay (PS)
Unplanned ICU/HD care (HD)
Nil (NI)

Department Comments
Problems
identified:

Risk/
Contributing
factors:

Learning
points/
Preventive
measures:

Modified from the A.I.M.S of Australian Patient Safety Foundation Inc. Created by Jimmy Phoo
June 1994 Version 5. 25/4/2011
 Append images to report if relevant
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Modified from the A.I.M.S of Australian Patient Safety Foundation Inc. Created by Jimmy Phoo
June 1994 Version 5. 25/4/2011