Anaesthetic incident reporting

The Perioperative Mortality Review Committee (POMRC) is an independent statutory committee that reviews and reports on perioperative deaths in New Zealand and advises the Health Quality & Safety Commission (HQSC) on how to reduce that number.

POMRC defines ‘perioperative death’ as deaths that occur during surgery; within 30 days of surgery; after 30 days of surgery, but before discharge from hospital; or while under the care of a surgeon in hospital, even if surgery was not undertaken.

For the purposes of POMRC’s definition of perioperative death, a surgery (or operative procedure) refers to any procedure requiring sedation or anaesthetic (local, regional or general).
 

The ACT Audit of Surgical Mortality (ACTASM) is an audit process that provides an independent, external peer review, that is systematic, objective and confidential. The purpose of ACTASM is to review all deaths that occur during an episode of surgical care and to provide opportunities for improvements in patient outcomes.

The ACTASM and ANZCA collaborate in the collection of anaesthetic-related surgical mortality. ACTASM is notified by the hospital of all deaths that occurred during a surgical admission, and an anaesthetist may be involved when the treating surgeon alerts the possibility of an anaesthetic component of the death.

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The Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) is a Ministerial Committee established to conduct peer review investigations into anaesthesia mortality.

Pursuant to section 84 of the NSW Public Health Act 2010, notifications are made to SCIDUA when a patient dies while under, within 24 hours after, or as a result of the administration of an anaesthetic or a sedative drug administered in the course of a medical, surgical or dental operation or procedure. 

As such deaths are deemed reportable days or even weeks after a procedure if an adverse event occurs during the procedure which later results in a patients death.  The 24 hours post procedure is not considered the time limit for reporting, it extends well beyond this.

SCIDUA is afforded privilege under section 23 of the Health Administration Act 1982 for the purpose of conducting research or investigations into morbidity and mortality.

Medical practitioners participating in SCIDUA are eligible for continuing professional development points under the ANZCA CPD Program.

The Northern Territory Audit of Surgical Mortality (NTASM) is an external, independent, peer review audit of the process of care associated with surgically related deaths in the territory.

The college and NTASM collaborate in the collection of anaesthetic-related surgical mortality. In cases where the possibility of an anaesthetic component of the death is identified, NTASM will send an anaesthetic case form to the treating anaesthetist for completion. An anaesthetist may also self-report a case if they wish.
 

The Queensland Perioperative and Periprocedural Anaesthetic Mortality Review Committee (QPPAMRC) collects and analyses clinical information regarding perioperative and periprocedural anaesthetic mortality in Queensland to identify statewide specific trends.

The committee functions collaboratively with the Statewide Anaesthesia and Perioperative Care Clinical Network (SWAPNET), other related networks and the Private Hospitals Association of Queensland.
 

The role of the South Australian Anaesthetic Mortality Committee (SAAMC) is to analyse adverse event information, specifically patient mortality, from health services related to anaesthesia with the objective of recommending quality improvement initiatives.

The South Australian Audit of Surgical Mortality (SAASM) has expanded surgical mortality audits to include a collaboration with the SAAMC. Where information provided by treating surgeons as part of the surgical mortality audit process identifies a potential anaesthetic component to the death of the patient, such cases are referred on to the SAAMC on a monthly basis for further anaesthetic assessment.

The documents below provide information and guidance on reporting deaths within 48 hours of an anaesthetic in South Australia, and the assessment of that report by the SAAMC:

The Tasmanian Audit of Anaesthesia Mortality (TAAM) operates in conjunction with, and under the governance of, the Tasmanian Audit of Surgical Mortality (TASM). The TASM sends a Surgical Case form to the treating surgeon or anaesthetist involved in the particular case.
 

The Victorian Perioperative Consultative Council (VPCC) oversees, reviews and monitors perioperative care in Victoria to improve outcomes for patients before, during and after surgery. All cases relating to perioperative mortality and morbidity, including surgical and anaesthetic, are reviewed by the VPCC.

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The Western Australian Anaesthetic Mortality Committee (WAAMC) analyses adverse event information, specifically patient mortality, from health services related to anaesthesia with the objective of giving feedback to the anaesthetists involved and identifying state-wide trends, to improve patient outcomes.

The documents below provide information and guidance on reporting deaths within 48 hours of an anaesthetic in WA, and the assessment of that report by the WAAMC:

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