Critical incident reporting systems

Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system

Agood safety culture may be predominantly defined by an open and unsanctioned communication about critical and erroneous courses. In an effort to improve patient safety various instruments, such as the critical incident reporting system (CIRS) or in terms of patient handover, the use of the situation, background, assessment, recommendation (SBAR) system patient handover, have been developed and are recommended by the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). This study aimed at identifying how anesthesiologists perceive the safety culture in their current department and whether CIRS or SBAR are already established or not. All registered members of the DGAI and the Professional Association of German Anaesthesiologists (BDA, n = 19,042) were invited to participate in an online survey on patient safety. In this survey there was afocus on the perceived safety culture and the experience with CIRS and SBAR. Of the participants 76.6% (n = 1372) stated that their department of anesthesiology has agood safety culture, while in 23.4% (n = 419) there was not. For the whole hospital the safety culture was only rated as being positive by 54.3% (n = 949) of the respondents. An open communication about critical and erroneous courses occurred in 76.5% (n = 1375) according to the participants, 23.0% (n = 408) had the impression that in the case of errors the respective person was being denounced. In one third of the participants' departments (n = 630, 36.6%) there were no morbidity and mortality conferences. The acronym CIRS was familiar to 98.9% (n = 1801) of the participants, 84.8% (n = 1544) of the surveyed anesthesiologists reported that CIRS was established in their departments. Critical incidents have been reported via CIRS by 54.4% (n = 839) of the respondents. Only 29.4% (n = 462) of the participants received regular feedback on CIRS reports. The acronym SBAR as ahandover tool is unknown to the majority of the surveyed participants (n = 1181, 63.7%) and 86.1% (n = 1554) consider using an instrument in order to improve handover quality as possibly being beneficial. Anesthesiologists rate the quality of the safety culture of their own anesthesiology department to be higher compared to their hospital in general. In some hospitals there is denouncement in cases of erroneous courses according to the respondents. In the patients' point of view morbidity and mortality conferences should be established more often. CIRS is known to almost every surveyed anesthetist but feedback on aregular basis is sparse. This contradicts the claims of the German Coalition for Patient Safety. The acronym SBAR is unknown to the majority of surveyed participants despite the recommendation of the DGAI to implement it. There is awish for tools in order to enhance the quality of handovers.

The Human Factors Analysis and Classification System (HFACS) was developed as a practical taxonomy to investigate and analyse the human contribution to accidents and incidents. Based on Reason's "Swiss Cheese Model", it considers individual, environmental, leadership and organizational contributing factors in four hierarchical levels. The aim of this study was to assess the applicability of a modified HFACS taxonomy to incident reports from a large, anonymous critical incident database with the goal of gaining valuable insight into underlying, more systemic conditions and recurring schemes that might add important information for future incident avoidance. We analysed 50 reports from an anonymous, anaesthesiologic, single-centre Critical Incident Reporting System using a modified HFACS-CIRS taxonomy. The 19 HFACS categories were further subdivided into a total of 117 nanocodes representing specific behaviours or preconditions for incident development. On an individual level, the most frequent contributions were decision errors, attributed to inadequate risk assessment or critical-thinking failure. Communication and Coordination, mostly due to inadequate or ineffective communication, was contributory in two-thirds of reports. Half of the reports showed contributory complex interactions in a sociotechnical environment. Ratability scores were noticeably lower for categories evaluating leadership and organizational influences, necessitating careful interpretation. We applied the HFACS taxonomy to the analysis of CIRS reports in anaesthesiology. This constitutes a structured approach that, especially when applied to a large data set, might help guide future mitigation and intervention strategies to reduce critical incidents and improve patient safety. Improved, more structured reporting templates could further optimize systematic analysis.

To assess the practicality of using personal digital assistants (PDAs) for the collection of logbook data, procedural performance data and critical incident reports in anaesthetic trainees. Pilot study. Two tertiary referral centres (in Victoria and New Zealand) and a large district hospital in Queensland. Six accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their ANZCA training supervisors. Registrars and supervisors underwent initial training for one hour, and supervisors were provided with ongoing support. Reliable use of the program, average time for data entry and number of procedures logged. ANZCA trainees reliably enter data into PDAs. The data can be transferred to a central database, where they can be remotely analysed before results are fed back to trainees. This technology can be used to monitor professional performance in ANZCA trainees.

Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room. We screened six open access and German language-based CIRS-platforms on the internet. We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents. Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.

We wanted to identify incidents that led or could have led to patient harm during prehospital cardiopulmonary resuscitation. A nationwide anonymous and Internet-based critical incident reporting system gave the data. During a 4-year period we received 548 reports of which 74 occurred during cardiopulmonary resuscitation. Human error was responsible for 85% of the incidents, whereas equipment failure contributed to 15% of the reports. Equipment failure was considered to be preventable in 61% of all the cases, whereas incidents because of human error could have been prevented in almost all the cases. In most cases, prevention can be accomplished by simple strategies with the Poka-Yoke technique. Insufficient training of emergency medical service physicians in Germany requires special attention. The critical incident reports raise concerns regarding the level of expertize provided by emergency medical service doctors.

PurposeThe purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses’ error reporting cost/benefit evaluations and associated behaviors.Design/methodology/approachA longitudinal survey study was carried out in a hospital setting with two measurements (time 1 [t1]: implementation of a critical incident reporting (CIR) system; t2: three months after t1). Correlational and hierarchical cluster analyses were used to interpret the data.FindingsPositive cost-benefit correlations and negative cross-correlations were found, with no substantial changes over time. “Reporters” and “learners” were differentiated regarding error-reporting behaviors. Cost-benefit perceptions predicted membership in the “reporters” group; perception of effort costs negatively predicted an error-reporting preference.Research limitations/implicationsThis study was limited, in that only a questionnaire was used to collect data.Practical implicationsStressing the benefits of CIR systems should contribute to reducing employees’ perception of reporting costs; thus, ease of use is a critical factor in CIR system use.Originality/valueThe study empirically probes a well-established theoretical model, and various ideas for further research are suggested.

The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety. A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented. The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period. Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).

Eleven anaesthetists completed a simulated anaesthetic which was deliberately complicated by a slow progressive bradycardia followed by an episode of severe bronchospasm. After the simulation, each anaesthetist was asked to complete an anaesthetic chart and a critical incident report. Considerable discrepancies were found between the anaesthetists' written accounts, a videotape of their performance and actual data from the simulator. During the simulations, all of the anaesthetists reacted appropriately and treated their patient successfully but their written accounts showed a tendency to record typical rather than actual events and to ignore events not consistent with their final diagnosis. Only four anaesthetists mentioned bradycardia in their written description and none accurately described the changes in arterial pressure during the episode of bronchospasm. The findings are in keeping with other studies which suggest that people record events as schemata rather than as collections of discrete facts. These results have significant implications for those involved in the teaching of anaesthesia and in the analysis of critical incidents.

Inaccurate reporting of simulated critical anaesthetic incidents

The authors put a much-needed focus on the validity of biomedical research results that has come under scrutiny. However, as they make clear, due to the complexity of the experiments involved, errors quite naturally occur frequently. A way of managing these errors is the “Laboratory Critical Incident and Error Reporting System” (LabCIRS), a software tool to record all incidents anonymously and to analyze, discuss, and communicate them. It has been adapted from the CIRS, used in the clinical world to improve patient safety in complex, fast-paced, and often understaffed settings.

Every year preventable adverse events endanger a considerable number of patients. Current guidelines of the Federal Joint Committee require clinical quality management to provide amongst others an independent clinical risk management and a critical incident reporting system (CIRS). Such guidelines increase the pressure to actively deal with errors, even in emergency medicine. Human error is considered to be the main cause of preventable adverse events in high-risk industries, such as aviation. This observation is gladly directly transferred to clinical medicine. This study investigated where the true causes for preventable adverse events during the resuscitation of severely injured patients can be found. A non-systematic literature search of the PubMed database was performed. The search identified three recent studies addressing these objectives that revealed human error as the most important cause of preventable adverse events during emergency room resuscitation (88-97%). Errors during resuscitation in the emergency room occur in approximately 10 %. It is striking that such data do not differ greatly from findings described in studies undertaken 20 years ago. One possible explanation might be that the systematic evaluation of medical errors in the emergency room is a weak spot and that too few lessons can be learnt from such incidents. Therefore, this article describes models of error development and outlines methods to collect data for root cause analysis and for clinical risk management. Thus, this review aims at a better understanding of how errors originate and to allow development of strategies to prevent errors from happening again. Human error is the most important cause of preventable adverse events during emergency room resuscitation. Presumably, errors occur unintentionally and as a result of situational misjudgment. As such errors have marked consequences on mortality and morbidity of severely injured patients, an extensive risk management is mandatory for the improvement of quality and safety. Appropriate methods to record errors in order to allow a correct root cause analysis according to well-established protocols is a basic prerequisite.

Listening to victims: Use of a Critical Incident Reporting System to enable adult victims of childhood sexual abuse to participate in a political reappraisal process in Germany

More patient safety through mehr-patientensicherheit.de? How a new platform strengthens the patient perspective

In this chapter, we describe the development of research about child sexual abuse in religiously affiliated and secular institutions in Germany that has been neglected for a long time. In 2010, the so-called abuse affair in Germany ignited a political debate over the extent of abuse committed by professional educators. At around the same time, the German government and the Roman Catholic Church in Germany each set up a contact point to gather information on child sexual abuse that had taken place within the church and secular institutions. In one of our analyses, we looked at a subset of the data, in order to compare the nature of abuse experienced in three types of institutions: Roman Catholic, Protestant, and secular. The results suggest that child sexual abuse in institutions is attributable to the nature of institutional structures more than to the attitudes towards sexuality of a specific religion. In another analysis, we compared data about sexual abuse in the Roman Catholic Church that has been collected through a church and through a government contact point. Some differences were found. These differences highlight the need for an effective complaint management system to offer not just one but complementary channels of communication. In addition, the findings confirm the feasibility and value of a critical incident reporting system (CIRS) approach and the use of so-called citizen science in politically driven review processes. Finally, we draft developments in politics, society and institutions concerning prevention and intervention strategies.