Evaluation of critical incidents in general surgery

Zingg, Urs; Zala-Mezoe, E.; Kuenzle, B.; Licht, A; Metzger, U; Grote, Gudela; Platz, Andreas

doi:10.1002/bjs.6296

Cited by 12 publications

(9 citation statements)

References 23 publications

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“…Our focus here is upon a distinction by Reason (1990Reason ( , 1995 that is frequently drawn upon in medical (Zingg et al 2008) and nursing (Bauer 2008;Unruh and Pratt 2007) research. Based upon different levels of action and action regulation, this concept distinguishes knowledgeand rule-based errors (KRE) 1 from slips and lapses (SL) (Reason 1995;Zhao and Olivera 2006).…”

Section: Negative Knowledge and Different Types Of Workplace Errorsmentioning

confidence: 99%

Workplace errors and negative knowledge in elder care nursing

Gartmeier

Bauer

Gruber

et al. 2010

Human Resource Development International

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Section: Negative Knowledge and Different Types Of Workplace Errorsmentioning

confidence: 99%

Workplace errors and negative knowledge in elder care nursing

Gartmeier

Bauer

Gruber

et al. 2010

Human Resource Development International

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“…This would allow exam of the incident within the context of a patient's journey. 71 While none of the reviewed studies applied the Yorkshire framework, 25 2 studies 48,51 referred to Reason's 59,75 and Vincent's 73 models of accident causation. None of the other studies applied a theoretical framework.…”

mentioning

confidence: 99%

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

Goekcimen¹,

Schwendimann

Pfeiffer

et al. 2022

J Patient Saf

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Introduction: Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths. Results:We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus. Conclusions:This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.

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“…Medical error is a critical issue in medical practice. A web-based adverse event reporting system for surgical patients has been developed [6] and incident analysis is conducted in the scenario of surgical setting [7]. As reporting systems largely depend on clinical staff input, the results can be subjective and there is a risk of intentional concealment.…”

Section: Introductionmentioning

confidence: 99%

Untitled

et al. 2013

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This paper introduces an intelligent operating theater equipped with a magnetic resonance imaging (MRI) scanner and video recording and broadcasting system to enhance the quality of surgery. To reduce error, intraoperative incidents are detected and dealt with using semi-automatic computer algorithm. A multiple-channel video recording and broadcasting system was installed in an operating room and the surgical procedure was recorded. The supervising surgeon monitored the operation in real-time from outside the operating room. Information sharing via the intra-hospital network improved the work efficiency of staff. The amount of motion was estimated from recorded file size based on the principle of inter-frame video compression. A time period for which the file size significantly increased compared to those for neighboring time periods was chosen and the majority voting technique was applied to detect events using six channels of the video. A change in file size indicated a phase change of the surgical procedure. The proposed method is promising for future daily clinical procedure.

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Evaluation of critical incidents in general surgery

Cited by 12 publications

References 23 publications

Workplace errors and negative knowledge in elder care nursing

Workplace errors and negative knowledge in elder care nursing

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

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