Voluntary incident reporting by anaesthetic trainees in an Australian hospital

Freestone, Liadaine; Bolsin, Stephen; Colson, Mark; Patrick, Andrew; Creati, Bernie

doi:10.1093/intqhc/mzl054

Cited by 33 publications

(31 citation statements)

References 30 publications

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“…The frequency of incidents reported from individual institutions has varied from 0.28% to 3.5% [8]- [13] while higher incidences of up to 12.1% [14] have also been reported. The difference in figures may be due to the variation in definitions of critical incidents and lack of accepted nomenclature [15] as well as individual perception and ambiguity in application.…”

Section: Discussionmentioning

confidence: 99%

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Zeng¹,

Ng²,

Thong³

2016

IJCM

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Introduction: Critical incident monitoring is important in quality improvement as it identifies potential risks to patients by analyzing adverse events or near-misses. Methods: This study analyses the reported incidents in a tertiary hospital over a 4-year period. Results: A total of 441 incidents were reported out of 98,502 anesthetics performed during the study period. Of these incidents, 67 resulted in no harm caused, 116 with unanticipated ICU admissions and 20 mortalities. The odds of having a critical incident increased with ASA status: from an odds ratio of 2.08 (95% CI: 1.58 to 2.74) for ASA 2 patients compared to ASA1, to OR of 13.70 (5.91 to 31.74) in ASA 5 compared to ASA 1. Critical incidents also have higher odds occurring out of hours (OR 1.7 (1.45 to 2.23) compared to daytime hours (08:00-17:00). They occurred most commonly in maintenance phase (142, 32.7%), followed by induction (120, 27.6%). The most common types of incidents include airway and respiratory (110, 24.9%) followed by drug related incidents (67, 15.2%). Human error was attributed as a significant contributing factor in 276 incidents (61.5%) followed by patient factors in 112 incidents (25.4%). Mitigating factors such as vigilance by staff involved were significant in 136 incidents (30.3%). Conclusion: Higher ASA status appears to be the most important factor associated with actual or potential patient harm in our study. Also significant, was time of incident, with incidents more likely out of hours. Critical incident reporting is a valuable part of quality assurance. We should continue to invest in incident reporting, incident analysis and improvement plans.

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Section: Discussionmentioning

confidence: 99%

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Zeng¹,

Ng²,

Thong³

2016

IJCM

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“…3 Encouraging the medical profession to report poor care and to report incidents that occur in their practice has been problematical in modern healthcare although there are notable exceptions. 4 This article discusses why a change in the attitude of the profession is required, what the benefits will be and how it can be achieved.…”

Section: Introductionmentioning

confidence: 99%

Whistleblowing and patient safety: the patient's or the profession's interests at stake?

Bolsin

Pal²,

Wilmshurst

et al. 2011

J R Soc Med

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“…Reporting systems have been implemented in several industrialized nations, such as the US, 12,25,28 Germany, 8,15,18,20 and Switzerland, which also introduced a critical national-incident reporting system. 4,11,13 Safety culture first developed in anesthesiology 5 and intensive care medicine, 2,10,15,19,24,25,28 then in other subspecialties such as hospital pharmacy, 11,22 internal medicine, 3,18 psychiatry, 27 obstetrics and gynecology, 13 pediatrics, 1,12 and ambulatory care. 4 Interestingly, in this regard, surgical subspecialties are still somehow underrepresented.…”

Section: Discussionmentioning

confidence: 99%

“…3) and its evolution into a health care error proliferation model effectively illustrates how the complexity of such systems, when combined with human factors, can synergistically promote errors. 10,22 Although this approach is widely accepted in aviation and some medical specialties, in surgery the question we usually ask is "Who is guilty?" rather than "Where has the system failed?"…”

Section: Discussionmentioning

confidence: 99%

Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

Ferroli

Caldiroli

Acerbi

et al. 2012

FOC

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Object Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. Methods In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Results Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Conclusions Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.

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Voluntary incident reporting by anaesthetic trainees in an Australian hospital

Abstract: ANZCA trainees in routine anaesthetic practice can reliably use mobile computing technology to report critical incidents and 'near miss' incident data.

Cited by 33 publications

References 30 publications

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

Whistleblowing and patient safety: the patient's or the profession's interests at stake?

Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

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