Clinical factors associated with the non-utilization of an anaesthesia incident reporting system

Critical incidents during anesthesia: prospective audit

BACKGROUND

Critical incident reporting and analysis is one of the key components of patient safety in anesthesiology. The aim of this study was to determine the frequency and characteristics of critical incidents during anesthesia, main causes and factors involved, influence on patient outcomes, prevalence of incident reporting and further analysis.

METHODS

A multicenter prospective audit was conducted at the clinical departments of the Bogomolets National Medical University during the period from 1 to 2021 to 1 December 2021. 13 hospitals from different Ukrainian regions took part in the study. Anesthesiologists voluntarily submitted critical incident reports into a Google form as they occurred during the working shifts, reporting the details of the incident, and the incident registration routine in their hospital. The study design was approved by the Bogomolets National Medical University (NMU) ethics committee, protocol #148, 07.09.2021.

RESULTS

The incidence of critical incidents was 9.35 cases per 1000 anesthetic procedures. Most common incidents were related to the respiratory system: difficult airway (26.8%), reintubation (6.4%), oxygen desaturation (13.8%); cardiovascular system: hypotension (14.9%), tachycardia (6.4%), bradycardia (11.7%), hypertension (5.3%), collapse (3.2%); massive hemorrhage (17%). Factors associated with critical incidents were elective surgery (OR 4.8 [3.1-7.5]), age from 45 to 75 years (OR 1.67 [1.1-2.5]), ASA II (OR 38 [13-106]}, III (OR 34 [12-98]) or IV (3.7 [1.2-11]) compared to ASA I; regional anesthesia (OR 0.67 95 CI 0.5-0.9) or general anesthesia (GA) and regional anesthesia combination (OR 0.55 95 CI 0.3-0.9] decreased the risk of incidents compared to GA alone. Procedural sedation was associated with increased risk of a critical incident, compared to GA (OR 0.55 95 CI 0.3-0.9). The incidents occurred most commonly during the maintenance phase (75/113, 40%, OR compared to extubation phase 20 95 CI 8-48) or the induction phases of anesthesia (70/118, 37%, OR compared to extubation phase 18 95 CI 7-43). Among common reasons that could lead to the incident, the physicians have identified: individual patient features (47%), surgical tactics (18%), anesthesia technique (16%) and human factor (12%). The most frequent failings contributing to the incident occurrence were: insufficient preoperative assessment (44%), incorrect interpretation of the patients' state (33%), faulty manipulation technique (14%), miscommunication with a surgical team (13%) and delay in emergency care (10%). Furthermore, 48% of cases, as judged by participating physicians, were preventable and the consequences of another 18% could be minimized. The consequences of the incidents were insignificant in over a half of the cases, but in 24.5% have led to prolonged hospital stay, in 16% patients required an urgent transfer to the ICU and 3% of patients died during their hospital stay. The majority of the critical incidents (84%) were reported through the hospital reporting system, using mostly paper forms (65%), oral reports (15%) and an electronic database (4%).

CONCLUSION

Critical incidents during anesthesia occur rather often, mainly during the induction or maintenance phases of anesthesia, and could lead to prolonged hospital stay, unplanned transfer to the ICU or death. Reporting and further analysis of the incident are crucial, so we should continue to develop the web-based reporting systems on both local and national levels.

STUDY REGISTRATION

NCT05435287, clinicaltrials.gov, 23/6/2022.

Analysis of Critical Incident Reporting System as an indicator of quality healthcare in a cardiology center in Tbilisi, Georgia

Critical Incident Reporting System (CIRS) have become most common patient safety tools in healthcare. The purpose of this study was to determine how effectively CIRS is used and how well healthcare professionals recognize it as a risk management tool. A quantitative approach using a cross sectional survey was adopted. The most common critical incidents were due to lack of personal attention and related to individual errors. The most of the critical incidents arise from non-adherence to guidelines and standards. CIRS can be seen as an effective clinical risk management tool that can be used to identify potential sources of critical incidents and help ensure patient safety at a healthcare organization.

Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia

BACKGROUND

Widespread recognition of the impact of healthcare adverse events has triggered incident reporting system implementation to promote patient safety. The aim was to assess the effectiveness, usability, enablers, and barriers of the Electronic Occurrence Variance Reporting System (eOVR) in addition to end user satisfaction.

METHODS

This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before and after implementing the eOVR.

OUTCOME MEASURES

Primary outcome measures: satisfaction and system usability, system security, workplace safety culture, training, and reporting trends. An overall satisfaction was collected. Secondary outcome: rate of reported OVRs per 1000 admissions. Furthermore, barriers and enablers to the reporting process were explored.

RESULTS

Study findings indicate that the eOVR has been successful in terms of high satisfaction according to respondents. Most of the respondents found the system easy to access, maintained patient confidentiality and reporting anonymity. Around half the respondents indicated having a non-punitive culture of reporting in their hospital. Physicians had significantly lower scores in all primary outcomes Incident reporting increased by 33.6% (p < 0.0001) after implementing the eOVR.

CONCLUSION

Successful incident reporting systems should be easy and simple to use, accessible and include features that guarantee anonymity and confidentiality. End-users should be trained prior to launching such a system. The implementation of such systems needs to be combined with promoting a just culture in the organization, timely feedback, more involvement and focus on physicians and junior staff which will improve user satisfaction and reporting rates.

Introducing Critical Incident Reporting System as an Indicator of Quality Healthcare in Georgia

Critical incident reporting systems (CIRS) have become the most common patient safety tools in healthcare. The purpose of this study was to present the development of CIRS in Georgia. A quantitative approach using a cross-sectional survey was adopted. Critical incidents were mainly derived from surgical disciplines. The highest number of cases was registered by nurses. The most common critical incidents were due to lack of personal attention. CIRS can be seen as an effective clinical risk management tool that can be used to identify potential sources of critical incidents and help ensure patient safety at a healthcare organization.

Critical Incidents during Anesthesia and Early Post-Anesthetic Period: A Descriptive Cross-sectional Study

INTRODUCTION

Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes. Studying those helps detect problems, which is crucial in minimizing their recurrence. We aimed to identify the frequency of peri-anesthetic critical incidents.

METHODS

This is a hospital-based descriptive cross-sectional study of voluntarily reported incidents, which occurred during anesthesia or following 24 hours among patients subjected to non-cardiac surgery within the calendar year 2019. Patient characteristics, anesthesia, and surgery types, category, context, and outcome of incidents were recorded in an indigenously designed form. Incidents were assigned to attributable (patient, anesthesia or surgery) factor, and were analyzed for the system,equipment or human error contribution.

RESULTS

Altogether 464 reports were studied, which consisted of 524 incidents. Cardiovascular category comprised of 345 (65.8%) incidents. Incidents occurred in 433 (93%) otherwise healthy patients and during 258 (55.6%) spinal anesthetics. Obstetric surgery was involved in 179 (38.6%) incidents. Elective surgery and anesthesia maintenance phase included the context in 293 (63%)and 378 (72%) incidents respectively. Majority incidents 364 (69.5%) were anesthesia-attributable, with system and human error contribution in 196 (53.8%) and 152 (41.7%) cases respectively. All recovered fully except for 25 cases of mortality, which were mostly associated with patient factors, surgical urgency, and general anesthesia.

CONCLUSIONS

Critical incidents occur even in low-risk patients during anesthesia delivery. Patient factors and emergency surgery contribute to the most serious incidents.

Critical incident analysis: Equip to avoid failure

This work is set in the context of perioperative practice in difficult airway management. It integrates a root cause analysis and fish bone technique to investigate a critical incident in temporary yet crucial equipment failure. Risk management and incident reporting is analysed alongside human factors in the operating theatre environment. Finally, recommendations for risk reduction, vigilance and checking vital airway equipment are made in anaesthetic practice.

Incident reporting systems: a comparative study of two hospital divisions

BACKGROUND

Previous studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions' use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process.

METHOD

The data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature.

RESULTS

The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback).

CONCLUSIONS

The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. Implications for practice are addressed.

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

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 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1-5]/10 and 3 [1-5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1-5]/10 (p=0.498).

CONCLUSION

This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health.

Incident reporting in post-operative patients managed by acute pain service

Background and Aims:

Incident reporting is a reliable and inexpensive tool used in anaesthesia to identify errors in patient management. A hospital incident reporting system was already present in our hospital, but we were unable to find any incident related to acute pain management. Hence, acute pain service (APS) was started for voluntary incident reporting in post-operative patients to identify critical incidents, review the root cause and suggest remedial measures.

Methods:

All post-operative patients managed by APS were included in this observational study. A proforma was developed by APS, which included information about the type of incident (equipment and patient-related, human errors), severity of incident, person responsible and suggestions to prevent the same incident in the future. Patients and medical staff were informed about the reporting system. Whenever an incident was identified, a proforma was filled out by APS resident and data entered in SPSS programme.

Results:

Total of 98 (1.80%) incidents were reported in 5432 patients managed by APS during 3 years period. Average age of the patients was 46 ± 17 years. Majority of incidents were related to epidural care (71%) and occurred in surgical wards (87%). Most of the incidents occurred due to human error and infusion delivery set-related defects.

Conclusion:

Incident reporting proved to be a feasible method of improving quality care in developing countries. It not only provides valuable information about areas which needed improvement, but also helped in developing strategies to improve care. Knowledge and attitudes of medical and paramedical staff are identified as the targeted area for improvement.

Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system

BACKGROUND

A loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS).

METHODS

Two experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making.

RESULTS

SA errors were identified in 81.5%. Predominantly, errors occurred on the levels of perception (38.0%) and comprehension (31.5%). Errors on the level of projection played a minor role (12.0%). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance.

CONCLUSIONS

SA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.

Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children

BACKGROUND

Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU).

AIM

The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected.

METHODS

With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA.

RESULTS

Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome).

CONCLUSION

With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services.

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting

Introduction

Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches.

Methods

We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature.

Results

‘Fixing and forgetting’ was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients’ safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was ‘fixing and reporting’ mentioned as a way that the providers dealt with problems that they could resolve.

Conclusions

We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice.

Experience Feedback Committee: a management tool to improve patient safety in mental health

BACKGROUND

A management tool, called the Experience Feedback Committee, has been applied for patient safety and successfully used in medical departments. The purpose of this study was to analyse the functioning of an Experience Feedback Committee in a psychiatric department and to explore its contribution to the particular issues of patient safety in mental health.

METHODS

We conducted a descriptive study based on all the written documents produced by the Experience Feedback Committee between March 2010 and January 2013. The study was conducted in Grenoble University Hospital in France. We analysed all reported incidents, reports of meetings and event analysis reports. Adverse events were classified according to the Conceptual Framework for the International Classification for Patient Safety.

RESULTS

A total of 30 meetings were attended by 22 professionals including seven physicians and 12 paramedical practitioners. We identified 475 incidents reported to the Experience Feedback Committee. Most of them (92 %) had no medical consequence for the patient. Eleven incidents were investigated with an analysis method inspired by civil aviation security systems. Twenty-one corrective actions were set up, including eight responses to the specific problems of a mental health unit, such as training to respond to situations of violence or management of suicide attempts.

CONCLUSIONS

The Experience Feedback Committee makes it possible to involve mental healthcare professionals directly in safety management. This tool seems appropriate to manage specific patient safety issues in mental health.

The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events

Background

The reduction of perioperative harm is a major priority of in-hospital health care and the reporting of incidents and their causes is an important source of information to improve perioperative patient safety. We explored the number, nature and causes of voluntarily reported perioperative incidents in order to highlight the areas where further efforts are required to improve patient safety.

Methods

Data from the Hospital Incident Management System (HIMS), entered in the period from July 2009 to July 2012, were analyzed in a Dutch university hospital. Employees in the perioperatve field filled out a semi-structured digital form of the reporting system. The risk classification of the reported adverse events and ‘near misses’ was based on the estimated patient consequences and the risk of recurrence, according to national guidelines. Predefined reported incident causes were categorized as human, organizational, technical and patient related.

Results

In total, 2,563 incidents (1,300 adverse events and 1,263 ‘near-miss’ events) were reported during 67,360 operations. Reporters were anesthesia, operating room and recovery nurses (37%), ward nurses (31%), physicians (17%), administrative personnel (5%), others (6%) and unmentioned (3%). A total of 414 (16%) adverse events had patient consequences (which affected 0,6% of all surgery patients), estimated as catastrophic in 2, very serious in 34, serious in 105, and marginally serious in 273 cases. Shortcomings in communication was the most frequent reported type of incidents. Non-compliance with Standard Operating Procedures (SOPs: instructions, regulations, protocols and guidelines) was reported with 877 (34%) of incident reports. In total, 1,194 (27%) voluntarily reported causes were SOP-related, mainly human-based (79%) and partially organization-based (21%). SOP-related incidents were not associated with more patient consequences than other voluntarily reported incidents. Furthermore ‘mistake or forgotten’ (15%) and ‘communication problems’ (11%) were frequently reported causes of incidents.

Conclusions

The analysis of voluntarily reported perioperative incidents identified an association between perioperative patient safety problems and human failure, such as SOP non-compliance, mistakes, forgetting, and shortcomings in communication. The data suggest that professionals themselves indicate that SOP compliance in combination with other human failures provide room for improvement.

National critical incident reporting systems relevant to anaesthesia: a European survey

BACKGROUND

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia.

METHODS

We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure.

RESULTS

Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed.

CONCLUSIONS

We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

Barriers to the operation of patient safety incident reporting systems in korean general hospitals

OBJECTIVES

This study aimed to explore the barriers to and factors facilitating the operation of patient safety incident reporting systems.

METHODS

A qualitative study that used a methodological triangulation method was conducted. Participants were those who were involved in or responsible for managing incident reporting at hospitals, and they were recruited via a snowballing sampling method. Data were collected via interviews or emails from 42 nurses at 42 general hospitals. A qualitative content analysis was performed to derive the major themes related to barriers to and factors facilitating incident reporting.

RESULTS

Participants suggested 96 barriers to incident reporting in their hospitals at the organizational and individual levels. Low reporting rates, especially for near misses, were the most commonly reported issue, followed by poorly designed incident reporting systems and a lack of adequate patient safety leadership by mid-level managers. To resolve and overcome these barriers, 104 recommendations were suggested. The high-priority recommendations included introducing reward systems; improving incident reporting systems, by for instance implementing a variety of reporting channels and ensuring reporter anonymity; and creating a strong safety culture.

CONCLUSIONS

The barriers to and factors facilitating incident reporting include various organizational and individual factors. As an important way to address these challenging issues and to improve the incident reporting systems in hospitals, we suggest several feasible methods of doing so.