Anonymes Meldesystem kritischer Ereignisse in der Anästhesie

Abstract

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.

Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety

“…The occurrence of incidents with respect to organization and processes [16,17], surgery and anaesthesia [18][19][20], and medication [6,[20][21][22][23][24][25] were described, too.…”

“…Several factors detrimental to a well-functioning CIRS can be identified: work overload (a higher workload has a negative effect on safety [39] and/or time pressure [7]), untrained staff (ignorance or lack of knowledge amongst staff members) [5,13,17,40], lack of feedback, lack of communication and/or team work [17], a poor quality of incident reports (inconclusive statements or too generic data) [9,10], and the collection of incident reports without an in-depth analysis [11]. During the implementation phase of a reporting system, resentments amongst staff members which affect the acceptance of CIRS might arise [41].…”

“…Several issues of further importance were found: (i) technical measures derived from incident reports may lead to new error resources [50]; (ii) the probable importance of national incident-reporting systems relevant to anaesthesia [31]; (iii) an inflationary push of CI-reporting systems without a sound comprehension or planning (see Ramanujam et al [30] for an example in medication); (iv) ineffectiveness in dealing with CI reports [4]; (v) the relationship between CIRS and related reporting systems with organizational quality management [52]; (vi) complementary approaches of CIRS [5,6,8,16,26]; and (vii) the dispute on the relationship between incident report frequency and patient safety [8,12,15,17,18,20,21,25,53].…”

Lipid emulsion for local anaesthetic toxicity

“…We believe that the recent case reports vindicate our early enthusiasm for lipid therapy [5][6][7] and provide support for our recommendation that lipid emulsion be immediately available wherever local anaesthetics are administered. We hope that the website initiative will reinforce the scientific foundation of lipid rescue as the initial burst of case reports passes and will improve general awareness and acceptance of the method.…”

Local anaesthetic toxicity: prevention or cure?

“…Our institution has, meanwhile, established a critical incident reporting system [6], which we consider to be the most powerful tool in detecting critical mistakes prior to disasters as reported above [7]. In addition, our institution regularly scans an electronic database of all anaesthetic records (kept since 1995 and now including about 50 000 local anaesthetic procedures) to detect rare events or near misses to improve of anaesthetic care [8].…”