The anaesthesia critical incident reporting system: an experience based database

Staender, Sven; Davies, Jan M.; Helmreich, B; Sexton, Bryan; Kaufmann, Mark

doi:10.1016/s1386-5056(97)00087-7

Cited by 92 publications

(48 citation statements)

References 4 publications

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“…In two previous studies, human errors were reported as the cause in 42% and 41% of the CI cases (6,9). Similarly, anaesthetists in our survey rated human error as the most frequent cause.…”

Section: Discussionsupporting

confidence: 81%

“…Maaløe et al (14) reported a relationship between the increased CI risk and old age, high ASA scores, urgency, abdominal surgery and a regional-general anaesthesia combination. Previous studies give conflicting results with various ASA scores, and mostly report induction and maintenance periods as risky for CI occurrence (6,9,14,23). Moreover, the vast majority of our anaesthetists (90.7%) think that the CI occurrence effects the duration of PACU and hospital and ICU stay.…”

Section: Discussionmentioning

confidence: 99%

“…The survey was based on previous published studies (3,6,11,12,(14)(15)(16) and was pilot tested on eight anaesthetists from our department to avoid misleading, inappropriate or redundant questions. Furthermore, the survey was checked for its compliance with the Helsinki Declaration.…”

Section: Methodsmentioning

confidence: 99%

“…The necessity of CIRS in anaesthesia is highlighted in terms of lowering the incidence of CIs and improving the patient safety (3,5,6). The frequency of voluntarily reported incidents from individual hospitals remains low (7)(8)(9)(10).…”

Section: Introductionmentioning

confidence: 99%

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Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Şalvız¹,

Edipoğlu²,

Orhan-Sungur³

et al. 2016

Turk J Anaesth Reanim

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Amaç: Kritik olay (KO) bildirim sistemi (KOBS) ve morbidite-mortalite toplantıları (MMT) hastalarda ortaya çıkabilecek riskleri belirleme avantajı sunar. Bunlar; kritik olayların analiz ve sonuçlarına göre klinisyen, hemşire, personel (insan hataları) davranışlarının ve hatta sistemin (insan ve/veya teknik hatalar) değiştirilmesiyle sağlık-bakım sisteminde hasta güvenliğini iyileştirilmede anahtar rol oynarlar.Yöntemler: Türkiye'deki tüm Üniversite (ÜH) ile Eğitim ve Araş-tırma Hastanelerinden (EAH) (n=114) seçilen uzman ve/veya daha kıdemli pozisyondaki bir anestezist ile irtibat kuruldu. Bu çalışmada ÜH ile EAH'de çalışan anestezistlerin KOBS ve MMT açısından imkanları ile aynı zamanda KO'lar hakkındaki bilgileri, deneyimleri ve davranışları tarafımızca araştırıldı. Bulgular:Yüz on dört eğitim hastanesinden 81 anestezist anketimizi yanıtladı. Anestezistlerin %96,3'ü KO bildirimini bir gereklilik olarak görmesine rağmen, sadece %37 bilim dalının/hastanenin KOBS'sinin olduğu belirtildi. KOBS'si olan anestezistlerin yalnız %23,3'ü KO'yu 'beklenmeyen/istenmeyen olay' şeklinde doğru tanımladı. Hastanelerin %60,5'inde MMT olduğu bildirildi. Bunlarla birlikte, anestezistlerin %96'sı KOBS ve MMT'nin KO ile karşılaşma sıklığını düşürdüğüne inandığını açıkladı. KO gelişimi ÜH'de ve EAH'de sırasıyla 4 [1-5]/10 ve 3 [1-5]/10 olarak insan hatasına bağlandı (p=0,005). Her iki hastane modelinde de teknik hatalar 3 [1-5]/10 olarak değerlendirildi (p=0,498).Sonuç: Türkiye Anestezi bilim dallarındaki/hastanelerindeki KOBS ile ilgili olarak yapılan bu ilk çalışma; TC Sağlık Bakanlığı tarafından hazırlanan bir güvenlik raporlama sistemi olmasına rağmen, KO bilgisinin, KOBS farkındalığının ve Anestezi bilim dalları/eğitim hastanelerindeki sistem kullanımının yetersizliğini göstermektedir.Anahtar kelimeler: Kritik olay, kritik olay bildirim sistemleri, morbidite-mortalite toplantıları, hasta güvenliği, anestezi Objective: Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. Methods:One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs. Results:Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in ...

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“…In two previous studies, human errors were reported as the cause in 42% and 41% of the CI cases (6,9). Similarly, anaesthetists in our survey rated human error as the most frequent cause.…”

Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Şalvız¹,

Edipoğlu²,

Orhan-Sungur³

et al. 2016

Turk J Anaesth Reanim

View full text Add to dashboard Cite

show abstract

“…Under reporting during on call hours is related to many factors like under supervision, denial of the fact that it is an error and desire to conceal if anything goes wrong. However, many investigators have concluded that voluntary reporting can result in underestimation of frequency of problems, but not necessarily the nature of problems [7]. Different causes of under reporting are present in literature with the reason of lack of ownership [11], lack of interest in sharing the experience and lack of time to fill these forms [12].…”

Section: Discussionmentioning

confidence: 99%

Critical Incident Reported in an Obstetric Unit of a Tertiary Care Hospital of a Developing Country, over a Period of Two Years

Abbasi¹

2017

OJOG

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Introduction: A lot of literature is available on critical incidents and near misses but specialty based critical incidents are very scanty. Aim: In this audit, we aimed to report critical incident and near misses during conduct of obstetric anesthesia over a period of two years. Methodology: Critical incident forms were collected, entered, analyzed and categorized on the basis of American Standards Association (ASA), phase of incidents, system involved, and type of errors, outcome and action taken. Human error was further categorized on the basis of their contributing factor marked in form. Results: During the reporting period, 5511 anaesthetics were administered and 55 reports were received out of which 53 reports were included in analysis. Fifty three reports were divided into 33 critical incidents and 20 near misses. Out of 33 critical incidents, 54.5% involved CVS system and musculoskeletal system, followed by neuromuscular (n = 5), drug related (n = 4), airway/respiratory system (n = 2), central nervous system (n = 2) and renal system (n = 1). Forty five incidents possess no untoward effect while 7 led to minor and only one to severe physiological disturbance. Human errors were (n = 30) 57% reports and failure to check was the main contributory factor. Conclusion: Critical incidents reporting needs to be introduced in sub-specialties at departmental, national and international level. Checking of equipment, medication and anesthesia machine must be part of regular checks in elective and emergency cases.

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Von der Schuldfrage zur Fehlerkultur in der Medizin

Haller

Fink

Patientensicherheit, Arzthaftung, Praxis- Und Krankenhausorganisation

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The anaesthesia critical incident reporting system: an experience based database

Cited by 92 publications

References 4 publications

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Critical Incident Reported in an Obstetric Unit of a Tertiary Care Hospital of a Developing Country, over a Period of Two Years

Von der Schuldfrage zur Fehlerkultur in der Medizin

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