Are complications under reported?

Dr Ashok Jadon, MD, DNB, MNAMS, FIPP

Chief Consultant Anaesthesia & Pain Relief Service, Tata Motors Hospital,

Jamshedpur

From darkness to light….

“Primum non nocicerum” — firstly, do no harm

Complications are biggest deterrent to achieve this.

Background…

1. To avoid, 2. To identify and prevent

collateral damage,3. To manage and treat if

occurred.

Three objectives

Hospital employees recognize and report only one out of seven errors,

In some cases, person assumed someone else would report the episode or

It is thought that it was so common that it did not need to be reported, or

“events were isolated incidents unlikely to recur”

cause ; fault in reporting system;

Are Complication under reported?

Over the years, the number of interventional procedures performed & the number of malpractice claims has increased dramatically

Prescribed protocols have not been followed or correct techniques have not been used.. There is no standardized body of knowledge

required for the field.. Individual physicians must police themselves as to

their competency and qualifications for safe practice…

Unfortunately, it appears that often this is not the case..

Why Are complications increasing..

We must classify event unanimously develop a list of “reportable events” We should have “detailed, unambiguous

instructions on the types of events that should be reported”

We must do Protocol based practice◦ Protocol War ◦ Which protocol◦ We have to decide

Suggestions..

Black swan event Pre procedure precautions… Physician attitude towards patients Repeated errors during conduct of

interventional procedures Effects of medical malpractice of

healthcare delivery Fear of reporting

Other issues related to under reporting..

Stellate ganglion Block; convulsion due to vertebral artery injection

Huntoon suggests that, the deep cervical vessels anterior to the transverse process may be involved in causing seizure during SGB.

Modified Technique for Stellate Ganglion Block avoids/minimizes the chance of vascular injury

Standard of Care… help?

un-diagnosed that’s why unreported

◦ Continuous updating & prevention of

complication:

Which group this complication belongs to?

◦ Classifying Complications of Interventional

Procedures

Suggestions…

Complications are increasing

Complications are under reported

How to improve reporting

How to reduce complications

Need for intervention …..??????

Strong Presumption

THANK YOU