Adverse events during anaesthesia at an Ethiopian referral hospital: a prospective observational study

Joe Burgess, Gebrehiwot Asfaw, Jolene Moore* (Corresponding Author)

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)
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Introduction: incident reporting systems are widely utilised within healthcare to analyse adverse events and have been shown to reduce patient harm. With data to suggest high anaesthetic-related mortality in low and middle-income countries (LMICs), such systems could allow more accurate determination of rates and types of incidents and could improve patient safety.

Methods: this prospective observational study carried out over six-weeks in March to April 2019 in an Ethiopian tertiary referral hospital, included direct observations in the operating room and recording of any anaesthesia-related adverse events occurring during the perioperative period.

Results: fifty surgical cases were observed during weekday daytime hours. Sixteen anaesthesia-related adverse events were observed in 12 patients, including six elective cases and six emergencies, an adverse event rate of 32% (n=16), affecting 24% (n=12) of patients. Most incidents occurred in infants less than one-year-old and those between 11-20 years (31.3%; n=5 each) and those undergoing general anaesthesia (66.7%; n=8), particularly during the induction phase (50%; n=8), the most common event being prolonged desaturation (31.3%; n=5). Most events were considered to contribute a low level of harm (56.3%; n=9). There were no intra-operative mortalities.

Conclusion: this study presents evidence of a higher rate of adverse events during anaesthesia at a tertiary referral hospital in Ethiopia, than reported in current literature from LMICs. There is potential for large volume data to be produced and learnt from with a reporting system in place in this setting. The most common event was desaturation detected by pulse oximetry, particularly in paediatric surgery.
Original languageEnglish
Article number375
Number of pages10
JournalPan African Medical Journal
Early online date16 Apr 2021
Publication statusPublished - 16 Apr 2021


  • Anaesthesia
  • Adverse event
  • Critical incident


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