The anaesthesia critical incident reporting system: an experience based database
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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