Two years ago we implemented a reporting system for critical incidents in the Department of Anaesthesiology and Intensive Care of the University Hospital Dresden. During the first 18 months 162 anonymous reports were registered. The most common errors involved airway and ventilation management, followed by errors in fluid and cardio-vascular management. The main causes were distraction, lack of experience, specific training and communication deficits. The confidence in the anonymity of the reporting system was very high. Following the analysis of the reports, several modifications were initiated, e.g. specific training programs or definition of standards. Over time, a change in the relative distribution of reported errors was observed. The article discusses the different kinds of errors and possible countermeasures. It also strengthens several aspects which are important to consider during the initial phase of a local critical incident reporting system.
Knowledge about the incidence of errors in anaesthesia and intensive care is only rudimentary but it appears justified to assume that errors occur much more often than we all expect. One reason is most likely the complexity of our work. Errors may alter our patients' health and healing process, imply financial and legal personal and institutional threats and may reduce health workers' performances. The article summarizes several methods to identify errors within a health care system and strengthens the importance of error analysis to reduce its incidence. Results of an analysis should be published if they are of general interest.
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).
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.