Improvements in anaesthetic care resulting from a critical incident reporting programme

SHORT, T. G.; O’Regan, Andrew; Jayasuriya, J. P.; ROWBOTTOM, M.; Buckley, Tom; Oh, T. E.

doi:10.1111/j.1365-2044.1996.tb04641.x

Cited by 21 publications

(34 citation statements)

References 17 publications

(2 reference statements)

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“…Human error in our study was a factor in 55% of incidents which is lower than that reported in the anaesthesia literature [1,4,18,20,21]. In the critical care literature an incidence of between 66% and 80% has been reported [7,11,17].…”

Section: Discussioncontrasting

confidence: 48%

“…Critical incident reporting is a well established QA in clinical anaesthesia [1][2][3][4][5][6]. However, there are significant differences regarding patient management between the operating theatre and the ICU.…”

Section: Discussionmentioning

confidence: 99%

“…Despite major advances in staff training and patient monitoring, appreciable morbidity and mortality attributable to mishaps still occur. Critical incident reporting is well established in anaesthesia [1][2][3][4][5][6] and several studies have now been published which highlight the role of both active and latent errors in the genesis of critical incidents. Until recently, little information was available regarding critical incidents [7][8][9][10][11] occurring in critically ill patients in the ICU especially when technically sophisticated procedures are performed on acutely ill patients with unstable physiology.…”

mentioning

confidence: 99%

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Critical incident reporting in the intensive care unit

et al. 1997

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SummaryCritical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our 'system' and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.

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Section: Discussioncontrasting

confidence: 48%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Critical incident reporting in the intensive care unit

et al. 1997

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“…The possibility of improvement in anesthetic care resulting from a critical incident reporting programme have also been studied by Short et al 28 They found no change in ampoule or syringe swaps, or general pharmacological incidents after increased awareness of problems at QA meetings and written reports, using a qualitative study design. It seems that the addition of 'visual and mental cues' is not strong enough alone to correct the mistakes.…”

Section: Impact Of Interventionmentioning

confidence: 99%

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Fasting

Gisvold

2000

Can J Anesth/J Can Anesth

158

149

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Purpose: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. Methods:We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity.Results: A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04).Conclusion: Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.Objectif: Décrire les erreurs de médicaments en anesthésie clinique selon leur fréquence et leur nature et éva-luer si une modification de la couleur des étiquettes codées des seringues pouvait, avec une certaine formation, résoudre ce problème. Conclusion : Les erreurs de médicaments sont rares et ne représentent qu'une petite partie des problèmes anesthésiques, mais elles sont toujours potentiellement dangereuses. Les échanges de seringues surviennent le plus souvent entre seringues de même taille et ils ne sont pas réduits par les étiquettes de couleurs codées. Les myorelaxants, le plus souvent en cause, peuvent entraîner une morbidité résiduelle. Des mesures préventives spéciales devaient être envisagées dans ce cas.

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“…Critical incident analysis was introduced to anaesthesia practice by Cooper et al [1] in 1978 and is now firmly established. This analysis can be used for auditing work practice, for correction of factors contributing to the incident and for identification of recurrent problems [2]. To date, the largest published series has been reported by the Australian Incident Monitoring Study (AIMS) [3].…”

mentioning

confidence: 99%

Drug related critical incidents

Khan

Hoda

2004

Anaesthesia

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SummaryDrug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect ⁄ drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.

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Improvements in anaesthetic care resulting from a critical incident reporting programme

Cited by 21 publications

References 17 publications

Critical incident reporting in the intensive care unit

Critical incident reporting in the intensive care unit

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Drug related critical incidents

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