Fig. 1

Case enrollment and classification. The figure shows the number of cases reported by anesthesiologists during the 11-year study period and the classification of the final case cohort for analysis. Examples of the different types of incidents are listed below. Airway incidents: intubation failure, bronchospasm or laryngospasm, dental or other oral tissue injury, endotracheal tube dislocation, postintubation hoarseness, aspiration, unplanned secondary intubation, and hypoxemia. MACE: severe hypotension, perioperative acute coronary syndrome, CPR, arrhythmia, cerebral infarction, hydrocephalus, and delirium. Only incidents of heart, brain or vascular origin were classified as this type. Pharmacological and transfusion incidents: drug- or blood product-related events during supply, storage, preparation, and administration; severe adverse drug reactions; anaphylactic reactions; and adverse transfusion events. Equipment incidents: incidents related to monitoring devices, respirators, gas supply systems, anesthesia devices, arterial or venous catheters, or endotracheal tubes. Spinal or regional anesthesia incidents: postdural puncture headache, nerve injury, local anesthetic intoxication, and total spinal anesthesia. Incidents related to surgery: massive bleeding and unplanned secondary operation. Other incidents: problems in multidisciplinary team corporation and communication, anesthesia record problems, and occupational exposure