A Cross-sectional Overview of the First 4,000 Incidents Reported to webAIRS, a De-identified Web-based Anaesthesia Incident Reporting System in Australia and New Zealand

Abstract

webAIRS is a web-based de-identified anaesthesia incident reporting system, which was introduced in Australia and New Zealand in September 2009. By July 2016, 4,000 incident reports had been received. The incidents covered a wide range of patient age (<28 days to >90 years), American Society of Anesthesiologists physical status, and body mass index (<18.5 to >50 kg/m2). They occurred across a wide range of anaesthesia techniques and grade of anaesthesia provider, and over a wide range of anaesthetising locations and times of day. In a high proportion the outcome was not benign; about 26% of incidents were associated with patient harm and a further 4% with death. Incidents appeared to be an ever-present risk in anaesthetic practice, with extrapolated estimates exceeding 200 per week across Australia and New Zealand. Independent of outcomes, many anaesthesia incidents were associated with increased use of health resources. The four most common main categories of incident were Respiratory/Airway, Medication, Cardiovascular, and Medical Device/Equipment. Over 50% of incidents were considered preventable. The narratives accompanying each incident provide a rich source of information, which will be analysed in subsequent reports on particular incident types. The summary data in this initial overview are a sober reminder of the prevalence and unpredictability of anaesthesia incidents, and their potential morbidity and mortality. The data justify current efforts to better prevent and manage anaesthesia incidents in Australia and New Zealand, and identify areas in which increased resources or additional initiatives may be required.

Patient and Procedural Factors Associated with An Increased Risk of Harm Or Death in the First 4,000 Incidents Reported to webAIRS

“…The method of webAIRS data collection and the categorisation of the first 4,000 incidents have been previously described, including details of the ethics approvals for the de-identified data analysis 1 . Of the 4,000 incidents, the patient outcome at the time of the incident was included in 3,583 reports: 2,514 no harm; 918 harm; and 151 death 1 . The outcome was not specified, or no particular patient was involved, in 417 reports.…”

Canadian Anesthesia Incident Reporting System (CAIRS): The Canadian Anesthesiologists’ Society’s National Patient Safety Initiative

“…17,18 Le Système canadien de déclaration des incidents d'anesthésie (CAIRS) repose sur webAIRS qui est l'IRS promu par l'ANZTADC (Comité tripartite Australie/Nouvelle-Zélande sur les données). Plus de 5 700 incidents critiques ont été déclarés sur webAIRS depuis 200 9,19 mais ils ne représentent presque certainement qu'un très faible pourcentage de tous les incidents d'anesthésie survenus en Australie en Nouvelle-Zélande au cours des neuf dernières années. La raison de ce relativement faible taux de déclaration pourrait être les multiples éléments décourageant la déclaration des incidents.…”

“…Le groupe d'anesthésies pédiatriques de Stanford a entrepris de multiples interventions pour améliorer les taux de déclaration. 19 Ses interventions ont inclus, notamment, l'inclusion de l'IRS dans le dossier médical électronique (DME), une série d'entretiens avec le corps professoral et une rétroaction détaillée aux utilisateurs. Ces étapes ont conduit à une augmentation significative du nombre d'incidents déclarés.…”

“…17,18 The Canadian Anesthesia Incident Reporting System (CAIRS) is based upon webAIRS, which is the IRS sponsored by the Australia New Zealand Tripartite Data Committee (ANZTADC). Despite the over 5,700 critical incidents that have been reported to webAIRS since 200 9,19 this almost certainly represents a very small percentage of the anaesthetic incidents that have occurred in Australia and New Zealand over the past nine years. The reason for the relatively low reporting rate might be the multiple disincentives to incident reporting.…”

“…The Pediatric Anesthesia Group at Stanford have undertaken multiple interventions to improve reporting rates. 19 Interventions included embedding the IRS within the electronic medical record (EMR), a series of interviews with faculty, and detailed feedback to the users. These steps lead to a significantly increased number of incidents being reported.…”