Clinical Case Database / Category: Case Based Discussion

Critical incidents in anaesthesia

Publication details

N. Tirlapur, E. Galtrey, J. Down
Foundation Years Journal, volume 6, issue 8, p.12 (123Doc Education, London, September 2012)


Critical incidents are unintended or unexpected incidents that may potentially cause patient harm. This article illustrates an example of a critical incident (CI) and discusses how to report a CI, what happens after a CI is reported, factors causing CIs, and methods to prevent or reduce harm from CIs.

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N. Tirlapur

Core Trainee in Anaesthesia
Centre for Anaesthesia, University College Hospital, London

E. Galtrey

Specialist Registrar in Anaesthesia
Centre for Anaesthesia, University College Hospital, London

J. Down

Consultant in Anaesthesia and Intensive Care
Centre for Anaesthesia, University College Hospital, London


1. Bould MD, Hunter D, Haxby EJ. Clinical risk management in anaesthesia. Continuing Education in Anaesthesia, Critical Care & Pain 2006, 6(6): 240-43.
2. National Patient Safety Agency guidelines. Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants: Patient Safety Alert; March 2011. resources/?EntryId45=129640
3. Mahajan RP. Critical incident reporting and learning. Br.J.Anaesth. 2010, 105(1): 69-75.
4. Health and Safety Executive paper. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. riddor/index.htm
5. NHS Scotland. NHS Scotland model for organisational risk management 2008.
6. Intensive Care Society guidelines. Standards for critical incident reporting in critical care.


Conflict Of Interest

The Journal requires that authors disclose any potential conflict of interest that they may have. This is clearly stated in the Journal’s published “Guidelines for Authors”. The Journal follows the Guidelines against Conflict of Interest published in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (

Financial Statement

The authors of this article have not been paid. The Journal is financed by subscriptions and advertising. The Journal does not receive money from any other sources. The decision to accept or refuse this article for publication was free from financial considerations and was solely the responsibility of the Editorial Panel and Editor-in-Chief.

Patient Consent statement

All pictures and investigations shown in this article are shown with the patients’ consent. We require Authors to maintain patients’ anonymity and to obtain consent to report investigations and pictures involving human subjects when anonymity may be compromised. The Journal follows the Guidelines of the Uniform Requirements for Manuscripts ( The Journal requires in its Guidelines for Authors a statement from Authors that “the subject gave informed consent”.

Animal & Human Rights

When reporting experiments on human subjects, the Journal requires authors to indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2008.

About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

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