Incident categories

Frequency

Percentage

Equipment related

5

25

Pressure bag applied on a used drip with 250 mls air

1

No suction pressure as suction bottle cap broken

1

Suction tube disconnected

1

Malfunction of operation table just after spinal

1

Oxygen analyzer was not working

1

Narcotic

3

15

Unlabeled narcotic

1

Expired Injection Pethidine in stock

1

Inj. Morphine given by pharmacy instead of Inj. Fentanyl

1

Infection control

3

15

Fungus in spinal pack

1

Sterile glove torn by sharp nails not noticed by primary person

1

No proper mask cap inside OR

1

Ampoule

2

10

poor quality ampoule lead to glass cut

1

Vasopressor not available in OR

1

Miscellaneous

7

35

Nurse left patient during spinal anaesthesia

2

Pre-operative evaluation and patient swap

1

Power cable kept on arm rest of OR table

1

Patient c/o pain in PACU but no one attending her

1

All surgical staff left OR and patient without information

1

Elective LSCS taken without consent

1

Total

20

100