Seventh Report of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity

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Introduction

The Victorian Consultative Council on Anaesthetic Mortality and Morbidity was established in 1976 under Section 13 of the 1958 Health Act.

The Council operates pursuant to Section 24 of the Health Act (as amended)

Terms of Reference of the Council

• To enquire into the circumstances of deaths and illnesses during or as a
  result of anaesthesia.
• To take such action as is appropriate to alleviate or to prevent the occurrence of such deaths or illnesses.
• To keep a register of such deaths or illnesses.
• To improve the practice of anaesthesia by publication of pertinent factors discovered during the enquiry.
• To report to the Minister annually upon anaesthesia generally and to make such recommendations as may seem appropriate.

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Contents:

• Introduction
  • Terms of Reference of the Council
• Membership of the Council
  • Operation of the Council
  • Confidentiality
  • Data Collection
  • Validity of Data
  • Uniformity of Coronial Legislation
  • National Survey on Anaesthetic Mortality
  • Relationship with Specialist Organisations
  • Output of the Council
  • Terminology
  • Anaesthetic Mortality
  • Anaesthetic Morbidity
  • Critical Incident
• Report on Cases Submitted to Council 1993–1996
  • Reports of Mortality and Morbidity
  • Classification of Cases Reported to the Council
• Mortality
  • Total Deaths Reviewed
  • Autopsy Rate
  • Causes of Death
• Anaesthetic Related Deaths
  • Causal or Contributory Factors
  • Age Distribution of Cases of Mortality
  • Risk Factors
  • Status of Anaesthetist
  • Location of Event
  • Type of Hospital
  • Type of Anaesthesia
  • Type of Surgery
• Morbidity
  • Reports of Morbidity
• Analysis of Causes of Anaesthesia Related
• Mortality and Morbidity
  • Aspiration of Gastric Contents
  • Pneumothorax
  • Acute Pulmonary Oedema
  • Pulmonary Embolism
  • Respiratory Obstruction or Failure
  • Drugs
  • Drugs Related Anaphylaxis
  • Drug Related Convulsions
  • Specific Problems with Regional Anaesthesia
  • Maternal Mortality
  • Pre-Operative Assessment
  • Iatrogenic Injuries
  • Hypotension, Myocardial Ischaemia and Cardiac Failure
  • Complications of Monitoring
  • Organisational Problems
• Conclusions
• Recommendations
• References

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