THE CENTRAL AFRICAN JOURNAL OF MEDICINE ORIGINAL ARTICLES ''Zy*

the purpose of improving the quality of care delivered by the department. Design: Cross sectional study. A critical incident was defined as ‘any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient’. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. Setting: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Subjects: Between May and October 2000, 62 completed critical incident forms were collected. Main Outcome Measures: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. Results: Atotal of 14165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92 % (130/14165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnograph