A | Airway | – | – | – |
B | Breathing (3 cases) | | | |
| Apnoea during LSCS (1), delayed respiratory depression (1) | 2 | – | – |
| Laryngeal nerve palsy | – | 1 | – |
C | Circulation (pulse) | – | – | – |
| Although some of the cases of hypotension and dysrhythmia may have been detected by feeling the pulse volume, these are included at the C stage of CD in the algorithm as they would be detected during the systematic check of the circulation (see Circulation, below) | | | |
| Colour (4 cases) | | | |
| Hypoxia during sedation | 2 | – | 1 |
| Hypoxia during positioning | 1 | – | – |
O | Oxygen supply to patient | – | – | – |
| Oxygen analyser | – | – | – |
V | Ventilation | – | – | – |
| Vaporisors (4 cases) | | | |
| Vaporiser left on | 2 | 1 | – |
| Overfilled vaporiser | 1 | – | – |
E | Endotracheal tube | – | – | – |
| Eliminate | – | – | – |
R | Review monitors (8 cases) | | | |
| Blood pressure measurement: inappropriate cuff application (1); not turned on (1); failure to measure (1); erroneous reading (1) | 4 | – | – |
| Capnograph: CO2 water trap missing | 1 | – | – |
| Electrocardiogram: incorrect rate | 1 | – | – |
| No foetal heart monitor | 1 | – | – |
| Hypothermia | 1 | – | – |
| Review equipment (8 cases) | 1 | – | – |
| Intravascular air | 1 | – | – |
| Surgeon punctured intravenous line | 1 | – | – |
| Leaking Haemaccel flask | 1 | – | – |
| No IV access – forgotten | 1 | – | – |
| Burn via diathermy | 1 | – | – |
| Drug fridge turned off | 1 | – | – |
| Wrong table | 1 | – | – |
| Fell off table | – | – | 1 |
C | Circulation (60 cases) | | | |
| Hypotension (25 spinal cases including 4 deaths, 10 epidural cases including 2 deaths, 1 brachial plexus case) | 35 | 1 | – |
| Bradycardia (7 spinal, 5 ophthalmic cases) | 7 | – | 5 |
| Hypertension (3 spinal) | 3 | – | – |
| Myocardial infarction (2 spinal, 1 epidural) | 3 | – | – |
| Ventricular tachycardia (1 spinal) | 1 | – | – |
| Supraventricular tachycardia (1 spinal, 1 ophthalmic) | 1 | – | 1 |
| Arrhythmia (1 brachial plexus) | – | 1 | – |
| Left ventricular failure (2 ophthalmic) | – | – | 2 |
D | Drugs (22 cases) | | | | |
| Wrong drug | Syringe swap | 5 | – | – |
| | Wrong local anaesthetic | 2 | – | – |
| Wrong concentration | | 6 | – | – |
| Drug not given | | 2 | – | – |
| Communication problem | Communication about subcutaneous heparin | 1 | – | – |
| | Communication about intrathecal morphine | 1 | – | – |
| Wrong route | Inadvertent epidural metaraminol | 2 | – | – |
| | Inadvertent epidural ranitidine | 1 | – | – |
| | Epidural infusion connected to intravenous infusion | 2 | – | – |