National Critical Incident Reporting Systems Relevant to Anaesthesia (original) (raw)
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National critical incident reporting systems relevant to anaesthesia: a European survey
British Journal of Anaesthesia, 2014
Editor's key points † Reliable incident reporting and dissemination of learning improves patient safety. † Establishing a 'no blame' safety culture and ensuring legal protection will encourage greater incident reporting. † Standardizing definitions, benchmarking, and closing the patient safety loop are important steps in this process.
StPierre_BJA_2014_National critical incident reporting.pdf
Editor's key points † Reliable incident reporting and dissemination of learning improves patient safety. † Establishing a 'no blame' safety culture and ensuring legal protection will encourage greater incident reporting. † Standardizing definitions, benchmarking, and closing the patient safety loop are important steps in this process.
A review of the situation in Europe 13 | 2009 Patient safety is an integral component of high quality healthcare services. In order to ensure, promote and support patient safety, regular monitoring and analysis of healthcare practices are required. Systems for reporting and analysing patient safety incidents are undoubtedly an essential tool in achieving this goal. This report reviews the present status and features of national patient safety incident reporting systems in Europe. Lessons learned from the European, as well as international experiences in patient safety reporting are examined and distilled to answer key questions of national level planning for patient safety. The report is a valuable aid for policy and decision makers concerned with patient safety development, as well as useful reference material for healthcare service managers, clinicians and researchers interested in patient safety, risk management, public health and health services research.
Anaesthesia and perioperative incident reporting systems: Opportunities and challenges
Best Practice & Research Clinical Anaesthesiology, 2020
Incident Reporting Systems (IRS) continue to be an important influence on improving patient safety. IRS can provide valuable insights into how to prevent patients from being harmed at the organizational level. But inadequate expectations and misuse, for performance assessment, patient safety measurement or research, have hindered the full IRS potential. Health care organizations need to develop effective strategies built on trust and truth telling to improve the impact of IRS. This requires strategies to address the limited resources to analyse the near-misses or adverse events; avoid the punitive drift through maintaining the anonymity and protective legislation; integrating IRS and avoiding its confusion with mandatory adverse event response systems; training data analysts to focus on the system instead of the individual through a balanced simple taxonomy; combine the analyses at the local level, to reinforce effective and personalized feedback, with the potential of a national or supranational learning platform.
A critical incident reporting systme in anaesthesia
Central African Journal of Medicine, 2001
Objective: To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with1 the purpose of improving the quality of care delivered by the department. Design: Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. Setting: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Subjects: Between May and October 2000, 62 completed critical incident forms were collected. Main Outcome Measures: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. Results: Atotal of 14165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57 %, oxymetry 90 % and ECG 100 %. Other monitors are not reported. Human error contributed in 32/62. of patients and equipment failure in 31/62 of patients. Patient outcome showed 15 % died, 23 % were unplanned admissions to HDU while 62 % were discharged to the ward with little or no adverse outcome. Conclusion: Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision o f juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change o f practice and improvement in the safety features of the service provided by the hospital and staff.
Reflections on patient safety incident reporting systems
2021
OBJECTIVE To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population's participation in reporting, and point out challenges in the Brazilian system. METHOD Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added. RESULTS Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature. FINAL CONSIDERATIONS In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, an...
Critical Incident Reporting in Anaesthesia: A Prospective Internal Audit
Indian Journal of …, 2009
Critical incident monitoring is useful in detecting new problems, identifying 'near misses' and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to ...
Revista de Calidad Asistencial, 2014
Objective: To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Design: Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Results: Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. Conclusions: The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems.
Feedback from incident reporting: information and action to improve patient safety
Quality and Safety …, 2009
Reporting system Healthcare domain Description of information/action feedback mechanisms and processes Ahluwalia and Marriott (2005) Critical Incident Reporting System 18 Neonatal Department (UK) c Regular multidisciplinary departmental meetings to discuss lessons learnt from reporting c Regular monthly department safety bulletin that includes summary of previous month's critical incident reports and a clinical lesson or guideline of the month. c Individual email bulletins, paper-based newsletters or bulletins posted on department website c Targeted campaigns aimed at a specific incident or pattern of incidents c Investigation of identified safety issues through Root Cause Analysis and Failure Modes and Effects Analysis to identify system failures for remedial action Amoore and Ingram (2002) Feedback notes for incidents involving medical devices 47 Medical equipment management in an NHS Trust (UK) c Feedback notes system developed as an educational tool to provide information on incident, equipment involved, causes and triggers uncovered by investigation, lessons learnt and positive actions taken by staff to minimise adverse consequences c Feedback notes issued to ward link nurses, used in teaching sessions and information disseminated to other hospital departments through annual nurse clinical update sessions and hospital intranet Gandhi et al (2005) Safety Reporting System 7 Brigham and Women's Hospital, Boston (US) c Feedback of issue progress by email to individual reporter and direct feedback of follow-up actions taken to original reporter to close the loop c Monthly article in staff bulletin to highlight safety issues c Safety improvements published quarterly in hospital newsletter c Monthly email circulated to front-line staff (anyone who reported) with summary of improvements made c Weekly reports of overdue follow-up on safety reports for nurse senior directors c Monthly patient safety leadership walkround visits c Quarterly report to higher levels of organisation including summary of actions taken to hospital leadership c Production of safety improvement actions and recommendations for follow-up, including prioritisation of opportunities and actions, assigning responsibility and accountability, and implementing the action plan c Changes implemented in clinical systems, processes or policy revisions c Patient or clinician education campaigns c Monitoring of clinical systems or processes c Clinical communications produced c Staffing adjustment or supervision Continued Error management c Regular multidisciplinary departmental meetings to discuss lessons learnt from reporting c Regular monthly department safety bulletin that includes a fixed reminder of the unit's agreed trigger list, summary of previous month's critical incident reports, data on admissions and activity levels and a clinical lesson or guideline of the month c Individual email bulletins, paper-based newsletters or bulletins posted on department website c Targeted campaigns aimed at a specific incident or pattern of incidents c Investigation of reported incidents and identified safety issues through Root Cause Analysis (retrospective) and Failure Modes and Effects Analysis (prospective) methods to identify system failures for remedial action Amoore and Ingram (2002) Feedback notes for incidents involving medical devices 47 Medical equipment management in a NHS Trust (UK) c Feedback notes system developed as an educational tool to provide information on incident, equipment involved, causes and triggers uncovered by investigation, lessons learnt and positive actions taken by staff to minimise adverse consequences c Feedback notes highlight positive actions taken by staff and provide anonymous information that allows staff to learn from why an incident occurred, in a supportive manner, while promoting a culture that supports learning c Feedback notes issued to ward link nurses, used in teaching sessions and information disseminated to other hospital departments through annual nurse clinical update sessions and hospital intranet Beasley et al. (2004) Primary care medical error reporting system 20 Wisconsin Primary care (US) c Report submitters, upon reporting to the system, receive reminders, composite data or commentary to encourage a two-way flow of information c Weekly or monthly newsletters that identify recent errors, their associated hazards and hazard control strategies c Presentation of aggregated error data to clinic administrators and care givers so that they can implement useful error or hazard prevention strategies c Educational information provided to patients so that they understand their role in helping to prevent errors Bolsin (2005) and Bolsin et al. (2005) PDAbased Clinician-led reporting system 49 50 Anaesthesiology Australia and New Zealand College of Anaesthetists ANZCA (Australia) c Automatic feedback of all reported incidents to local organisational quality managers and morbidity and mortality coordinators c Automated analysis and secure transmission of performance data back to reporting clinician, who has personal access to tracked data c Professional groups, colleges and specialist associations can apply for access to data at suitable levels of aggregation for use in monitoring training performance, for example Gandhi et al. (2005) Safety Reporting System 7 Brigham and Women's Hospital, Boston (US) c Feedback of issue progress by email to individual reporter and direct feedback of follow-up actions taken to original reporter to ''close the loop'' c Monthly article in staff bulletin to highlight safety issues c Safety improvements published quarterly in hospital newsletter c Monthly email circulated to front-line staff (anyone that reported) with summary of improvements made c Weekly reports of overdue follow-up on safety reports for nurse senior directors c Monthly patient safety leadership walkround visits c Quarterly report to higher levels of organisation including summary of actions taken to hospital leadership c Production of safety improvement actions and recommendations for follow-up, including prioritisation of opportunities and actions, assigning responsibility and accountability, and implementing the action plan Holzmueller et al. (2005), Lubomski et al.