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Standards Expected While Reporting a Critical Incident

Section Editor(s): Saidman, LawrenceJayaram, Raja MD, EDIC

doi: 10.1213/01.ane.0000269689.31393.40
Letters to the Editor: Letters & Announcements
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Central Manchester & Manchester Children's University Hospitals NHS Trust; Manchester, UK

Dr. Sharma does not wish to respond.

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To the Editor:

A recent report of death after accidental intrathecal injection of tranexamic acid (1) is deficient in not describing the results of a “root cause analysis” that should be part of the investigation following any critical incident (2) and in not reporting the results of the autopsy. In other words, the circumstances that led to the incident need to be analyzed to reduce the potential for a repeat of the circumstances that lead to the original disaster.

Raja Jayaram, MD, EDIC

Central Manchester & Manchester Children's University Hospitals NHS Trust

Manchester, UK

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REFERENCES

1. Garcha PS, Mohan CV, Sharma RM. Death after an inadvertent intrathecal injection of tranexamic acid. Anesth Analg 2007;104:241–2
2. Cohen MR, Proulx SM, Crawford SY. Survey of hospital systems and common serious medication errors. J Healthc Risk Manag 1998;18:16–27
© 2007 International Anesthesia Research Society