Anaesthesia and perioperative incident reporting systems: Opportunities and challenges

Measuring and monitoring perioperative patient safety: a basic approach for clinicians

“…activities) and ‘outcomes’ (results) [ 22 ]. Four measurement methods are presented in the following section that gauge mutually complementary aspects of patient safety issues (see Table 1 ) [ 1 ▪▪ , 24 , 25 ▪ , 26 ▪ , 27 – 37 , 38 ▪ , 39 , 40 – 56 ].…”

“…Using this case-based approach, frequently occurring and ‘typical’ problems, as well as rare but potentially serious events, can be described in meticulous detail [ 57 ▪ ]. Using an incident reporting system [ 1 ▪▪ , 19 , 26 ▪ ], these qualitative data are usually collected anonymously, and reports can be disseminated within the local institution or within the wider professional community [ 24 ]. Incident reporting is an invaluable way of learning about the essence, nature and specific mechanisms (’pathophysiology’) of safety issues.…”

“…Analysis of reports using structured protocols and root cause analysis (e.g., the ‘London Protocol’ [ 12 , 58 ]) may reveal local system weaknesses, and allow tailoring of local solutions [ 26 ▪ ]. As root cause analysis is time-consuming and labour-intensive, more rapid but less in-depth alternative techniques have been described, which should be combined according to the context [ 25 ▪ ].…”

“…If specific incident patterns are frequently observed, or reveal important risks, locally adapted safety indicators can be developed and used for rate-based measurements. Interestingly, incident reporting systems appear to be most effective when owned by clinical teams and when data analysis and action implementation occur locally [ 26 ▪ ].…”

“…Limitations of incident reporting follow from its methodical features. Because the reference population (denominator) for a particular type of event is mostly not known, it does not make sense to calculate incident rates or use their numbers or trends as a measure of safety [ 1 ▪▪ , 26 ▪ ]. Other common limitations of incident reporting include many barriers [ 4 ▪ , 27 ], related underreporting, as well as hindsight bias [ 1 ▪▪ ].…”