Critical incident reports concerning anaesthetic equipment: Analysis of the UK National Reporting and Learning System (NRLS) data from 2006

Cassidy, Christopher; Arnot-Smith, J.; Smith, A. F.

doi:10.1097/00003643-200805001-00022

Cited by 20 publications

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“…This by other organisations, and in addition reviewed incidents reported to the MHRA and the National Reporting and Learning Service (NRLS) of the NPSA [2]. The accompanying Checklist for Anaesthetic Equipment 2012 has been completely reformatted (Fig.…”

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confidence: 99%

Checking Anaesthetic Equipment 2012

et al. 2012

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Summary A pre‐use check to ensure the correct functioning of anaesthetic equipment is essential to patient safety. The anaesthetist has a primary responsibility to understand the function of the anaesthetic equipment and to check it before use. Anaesthetists must not use equipment unless they have been trained to use it and are competent to do so. A self‐inflating bag must be immediately available in any location where anaesthesia may be given. A two‐bag test should be performed after the breathing system, vaporisers and ventilator have been checked individually. A record should be kept with the anaesthetic machine that these checks have been done. The ‘first user’ check after servicing is especially important and must be recorded.

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confidence: 99%

Checking Anaesthetic Equipment 2012

et al. 2012

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“…The survey was based on previous published studies (3,6,11,12,(14)(15)(16) and was pilot tested on eight anaesthetists from our department to avoid misleading, inappropriate or redundant questions. Furthermore, the survey was checked for its compliance with the Helsinki Declaration.…”

Section: Methodsmentioning

confidence: 99%

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Şalvız¹,

Edipoğlu²,

Orhan-Sungur³

et al. 2016

Turk J Anaesth Reanim

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Amaç: Kritik olay (KO) bildirim sistemi (KOBS) ve morbidite-mortalite toplantıları (MMT) hastalarda ortaya çıkabilecek riskleri belirleme avantajı sunar. Bunlar; kritik olayların analiz ve sonuçlarına göre klinisyen, hemşire, personel (insan hataları) davranışlarının ve hatta sistemin (insan ve/veya teknik hatalar) değiştirilmesiyle sağlık-bakım sisteminde hasta güvenliğini iyileştirilmede anahtar rol oynarlar.Yöntemler: Türkiye'deki tüm Üniversite (ÜH) ile Eğitim ve Araş-tırma Hastanelerinden (EAH) (n=114) seçilen uzman ve/veya daha kıdemli pozisyondaki bir anestezist ile irtibat kuruldu. Bu çalışmada ÜH ile EAH'de çalışan anestezistlerin KOBS ve MMT açısından imkanları ile aynı zamanda KO'lar hakkındaki bilgileri, deneyimleri ve davranışları tarafımızca araştırıldı. Bulgular:Yüz on dört eğitim hastanesinden 81 anestezist anketimizi yanıtladı. Anestezistlerin %96,3'ü KO bildirimini bir gereklilik olarak görmesine rağmen, sadece %37 bilim dalının/hastanenin KOBS'sinin olduğu belirtildi. KOBS'si olan anestezistlerin yalnız %23,3'ü KO'yu 'beklenmeyen/istenmeyen olay' şeklinde doğru tanımladı. Hastanelerin %60,5'inde MMT olduğu bildirildi. Bunlarla birlikte, anestezistlerin %96'sı KOBS ve MMT'nin KO ile karşılaşma sıklığını düşürdüğüne inandığını açıkladı. KO gelişimi ÜH'de ve EAH'de sırasıyla 4 [1-5]/10 ve 3 [1-5]/10 olarak insan hatasına bağlandı (p=0,005). Her iki hastane modelinde de teknik hatalar 3 [1-5]/10 olarak değerlendirildi (p=0,498).Sonuç: Türkiye Anestezi bilim dallarındaki/hastanelerindeki KOBS ile ilgili olarak yapılan bu ilk çalışma; TC Sağlık Bakanlığı tarafından hazırlanan bir güvenlik raporlama sistemi olmasına rağmen, KO bilgisinin, KOBS farkındalığının ve Anestezi bilim dalları/eğitim hastanelerindeki sistem kullanımının yetersizliğini göstermektedir.Anahtar kelimeler: Kritik olay, kritik olay bildirim sistemleri, morbidite-mortalite toplantıları, hasta güvenliği, anestezi Objective: Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. Methods:One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs. Results:Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in ...

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“…The listed items are the result of consensus decisions by experts and summarise best evidence at the time of publication. In order to remain relevant, such guidelines are updated regularly in response to critical incident reports [11] and where the introduction of new equipment necessitates modification of the checklist. Checking an anaesthetic machine by using the AAGBI checklist provides evidence that due care and diligence has been applied in at least that part of an anaesthetist's work.…”

Section: Prevention Of Errormentioning

confidence: 99%

Cognitive aids: time for a change?

Jenkins

2014

Anaesthesia

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Critical incident reports concerning anaesthetic equipment: Analysis of the UK National Reporting and Learning System (NRLS) data from 2006

Cited by 20 publications

References 0 publications

Checking Anaesthetic Equipment 2012

Checking Anaesthetic Equipment 2012

Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

Cognitive aids: time for a change?

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