The anaesthesia critical incident reporting system: an experience based database

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Abstract

To date there have been fewer than a dozen studies on the nature of, and contributory factors in, critical incidents (CI) in anaesthesia. The first of these, by Cooper and colleagues, showed that the vast majority of their CI involved human error [1]. Most recently, the on-going Australian Incident Monitoring Study (AIMS), with now more than 2000 reports, has shows that aspects of `system failure' may constitute the bulk of the contributory factors, even though some human error may be detected in about 80% of the analysed cases [2]. We set up a Critical Incident Reporting System (CIRS) to collect anonymous CI in anaesthesia using a reporting form on the Internet. CIRS analysis of the first 60 cases corroborates the findings of previous CI studies. In addition, our preliminary results have shown certain important trends, especially those concerning the contributory factor of communication in the Operating Theatre. Although to date we are unable to assess the educational importance of these CI reports, we believe that there is great potential for this aspect of CIRS.

Introduction

Assessment of the structure, process and outcome of care is very important in todays high-tech medicine. In anaesthesia, the quality of the structure and process of care has been addressed, for example, by determining the numbers of anaesthetic-related deaths in the perioperative period. However, death due to anaesthesia alone is too rare to be useful as the sole index of systematically assessing the quality of routine anaesthetic practice. For example, the Confidential Enquiry into Perioperative Deaths (CEPOD) showed that anaesthesia was considered to have been wholly responsible for a fatal outcome in three out of half a million procedures [3]. Therefore, measuring the quality of anaesthesia should be included (but is not limited to) critical incident monitoring, morbidity and mortality, systematic assessment of individual and team performance, patient satisfaction, and cost-benefit analysis. Of these, critical incident monitoring is attractive because of the greater frequency of CI than of that of complications or accidents.

There is an increasing number of studies on the nature of and contributory factors in CI. The earliest of these, by Cooper and colleagues, showed that the vast majority of CI involve human error [1]. Most recently, the ongoing Australian Incident Monitoring Study (AIMS) with now more than 2000 reports, has shown that aspects of `system failure' may constitute the bulk of the contributory factors, even though some human error may be detected in about 80% of the analysed cases [2]. (These results are in line with the current thinking about the evolution of anaesthetic complications [4].)

Critical incident reporting in anaesthesia can thus serve as a tool to monitor the quality of anaesthetic care (both its structure and process) and give insight into the nature of critical incidents. In addition, CI reports can form the basis of a collection of important cases, which may be used for teaching at all levels of learner.

Section snippets

Methods

Inspired by the experiences in aviation (Aviation Safety Reporting System; ASRS) we set up a system to collect anonymous critical incidents in anaesthesia using a reporting form on the Internet. With this form we wanted to gain insight into the nature of critical events and collect cases, that might have a teaching potential for other anaesthetists.

A critical incident was defined as any deviation from the expected course, with the strong potentia for an adverse outcome. A HTML reporting form

Results

Sixty cases have been entered since the start of the project in April, 1996. Of these, 74% were elective cases and 26% were emergency procedures. The average American Society of Anesthesiology (ASA) Classification of Physical Status (a simple numerical description of how well the patient was at the time of presentation to the Operating Theatre) was 2.3 for the elective and 3.5 for the emergency cases (where 1=perfectly well and 5=will not live more than 24 h with or without the operation).

Discussion and conclusions

We have demonstrated that the CIRS form works as a tool to report CI in anaesthesia and may be used by anaesthetists of varying experience. Analysis of the first 60 cases corroborates the findings of other critical incident studies using more traditional modalities of data collection (interviews, and paper questionnaires). In addition, CIRS permitted the detection of certain important trends, particularly the factor of communication in the Operating Theatre.

A central problem with all critical

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    Incident reporting systems are used to collect and store data regarding such incidents. They are now widespread in most organisations (Jacobsson et al., 2011, 2012; Nielsen et al., 2006) and are used in most safety critical domains, including aviation (e.g. Aviation Safety Reporting System, NASA), healthcare (e.g. Critical Incident Reporting System, Staender et al., 1997) and heavy industry (e.g. MARS, Lindberg et al., 2010). Moreover, the use of an incident reporting system is one of the demands specified in the international occupational health and safety management system OHSAS18001, one of the world's most widely utilised OHS and safety management system standards (Nielsen et al., 2006).

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