Reporting critical incidents in a tertiary hospital: a historical cohort study of 110,310 procedures

Karin E Munting, Bas van Zaane, Antonius N J Schouten, Leo van Wolfswinkel, Jurgen C de Graaff, Karin E Munting, Bas van Zaane, Antonius N J Schouten, Leo van Wolfswinkel, Jurgen C de Graaff

Abstract

Purpose: Investigation of adverse events associated with anesthetic procedures is a method of quality control that identifies topics to improve clinical care and patient safety. Most research to date has been based on closed claim registries and anonymous reports which have specific limitations. Therefore, to evaluate a hospital's reporting system, the present study was designed to describe critical incidents that anesthesiologists voluntarily and non-anonymously reported through an anesthesia information management system.

Methods: This is a historical observational cohort study on patients (age > 18 yr) undergoing anesthetic procedures in a tertiary referral hospital. A 20-item list of complications, as developed by the Netherlands Society of Anesthesiologists, was prospectively completed for each procedure. All critical incidents registered in the anesthesia information management system were then reclassified into 95 different critical incidents in a reproducible way.

Results: There were 110,310 procedures performed in 65,985 patients, and after excluding 158 reports that did not depict a critical incident, 3,904 critical incidents in 3,807 (3.5%) anesthetic procedures remained. Technical difficulties with regional anesthesia (n = 445; 40 per 10,000 anesthetics; 95% confidence interval [CI], 36 to 44), hypotension (n = 432; 39 per 10,000 anesthetics; 95% CI, 35 to 43), and unexpected difficult intubation (n = 216; 20 per 10,000 anesthetics; 95% CI, 18 to 23) were the most frequently documented critical incidents.

Conclusion: Accurate measurement and monitoring of critical incidents is crucial for patient safety. Despite the risk of underreporting and probable misclassification of manual reporting systems, our results give a comprehensive overview on the occurrence of voluntarily reported anesthesia-related critical incidents. This overview can direct development of a new reporting system and preventive strategies to decrease the future occurrence of critical incidents.

Figures

Figure
Figure
Flow diagram for reclassification of critical incidents

References

    1. The Health Care Inspectorate. Basic set of quality indicators for hospitals 2012 (Dutch). Available from URL: (accessed July 2015).
    1. World Health Organization. World Alliance for Patient Safety. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. Switzerland: WHO Press; 2005. Available from URL: (accessed July 2015).
    1. Staender S, Kaufmann M, Scheidegger D. Critical incident reporting. with a view on approaches in anaesthesiology. In: Safety in Medicine. Amsterdam New York: Pergamon Elsevier Science; 2000: 65-82.
    1. Staender S, Schaer H, Clergue F, et al. A Swiss anaesthesiology closed claims analysis: report of events in the years 1987-2008. Eur J Anaesthesiol. 2011;28:85–91. doi: 10.1097/EJA.0b013e3283414fea.
    1. Whitaker DK, Brattebo G, Smith AF, Staender SE. The Helsinki Declaration on patient safety in anaesthesiology: putting words into practice. Best Pract Res Clin Anaesthesiol. 2011;25:277–290. doi: 10.1016/j.bpa.2011.02.001.
    1. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–1157. doi: 10.1136/bmj.316.7138.1154.
    1. Hubler M, Mollemann A, Metzler H, Koch T. Adverse events and adverse event reporting systems (German) Anaesthesist. 2007;56(1067-8):1070–1072.
    1. Choy CY. Critical incident monitoring in anaesthesia. Curr Opin Anaesthesiol. 2008;21:183–186. doi: 10.1097/ACO.0b013e3282f33592.
    1. Cooper JB. Towards patient safety in anaesthesia. Ann Acad Med Singapore. 1994;23:552–557.
    1. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105:69–75. doi: 10.1093/bja/aeq133.
    1. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims’ analysis. Best Pract Res Clin Anaesthesiol. 2011;25:263–276. doi: 10.1016/j.bpa.2011.02.007.
    1. Banks IC, Tackley RM. A standard set of terms for critical incident recording? Br J Anaesth. 1994;73:703–708. doi: 10.1093/bja/73.5.703.
    1. Schwilk B, Muche R, Treiber H, Brinkmann A, Georgieff M, Bothner U. A cross-validated multifactorial index of perioperative risks in adults undergoing anaesthesia for non-cardiac surgery. Analysis of perioperative events in 26907 anaesthetic procedures. J Clin Monit Comput 1998; 14: 283-94.
    1. Staender S, Davies J, Helmreich B, Sexton B, Kaufmann M. The anaesthesia critical incident reporting system: an experience based database. Int J Med Inform. 1997;47:87–90. doi: 10.1016/S1386-5056(97)00087-7.
    1. Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:520–528.
    1. Gupta S, Naithani U, Brajesh SK, Pathania VS, Gupta A. Critical incident reporting in anaesthesia: a prospective internal audit. Indian J Anaesth. 2009;53:425–433.
    1. Fasting S, Gisvold SE. Data recording of problems during anaesthesia: presentation of a well-functioning and simple system. Acta Anaesthesiol Scand. 1996;40:1173–1183. doi: 10.1111/j.1399-6576.1996.tb05547.x.
    1. Short TG, O’Regan A, Jayasuriya JP, Rowbottom M, Buckley TA, Oh TE. Improvements in anaesthetic care resulting from a critical incident reporting programme. Anaesthesia. 1996;51:615–621. doi: 10.1111/j.1365-2044.1996.tb07841.x.
    1. Madzimbamuto FD, Chiware R. A critical incident reporting system in anaesthesia. Cent Afr J Med. 2001;47:243–247.
    1. Kawashima Y, Seo N, Tsuzaki K, et al. Annual study of anesthesia-related mortality and morbidity in the year 2001 in Japan: the outlines-report of Japanese Society of Anesthesiologists Committee on Operating Room Safety (Japanese) Masui. 2003;52:666–682.
    1. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49:399–406. doi: 10.1097/00000542-197812000-00004.
    1. Morgan C. Incident reporting in anaesthesia. Anaesth Intensive Care. 1988;16:98–100.
    1. de Graaff JC, Sarfo MC, van Wolfswinkel L, van der Werff DB, Schouten AN. Anesthesia-related critical incidents in the perioperative period in children; a proposal for an anesthesia-related reporting system for critical incidence in children. Paediatr Anaesth. 2015;25:621–629. doi: 10.1111/pan.12623.
    1. Staender S. Incident reporting in anaesthesiology. Best Pract Res Clin Anaesthesiol. 2011;25:207–214. doi: 10.1016/j.bpa.2011.01.005.
    1. Benson M, Junger A, Fuchs C, et al. Using an anesthesia information management system to prove a deficit in voluntary reporting of adverse events in a quality assurance program. J Clin Monit Comput. 2000;16:211–217. doi: 10.1023/A:1009977917319.
    1. Sanborn KV, Castro J, Kuroda M, Thys DM. Detection of intraoperative incidents by electronic scanning of computerized anesthesia records. Comparison with voluntary reporting. Anesthesiology. 1996;85:977–987. doi: 10.1097/00000542-199611000-00004.
    1. Simpao AF, Pruitt EY, Cook-Sather SD, Gurnaney HG, Rehman MA. The reliability of manual reporting of clinical events in an anesthesia information management system (AIMS) J Clin Monit Comput. 2012;26:437–439. doi: 10.1007/s10877-012-9371-z.
    1. Stanhope N, Crowley-Murphy M, Vincent C, O’Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5:5–12. doi: 10.1046/j.1365-2753.1999.00146.x.
    1. Freestone L, Bolsin SN, Colson M, Patrick A, Creati B. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care. 2006;18:452–457. doi: 10.1093/intqhc/mzl054.
    1. Hubler M, Mollemann A, Eberlein-Gonska M, Regner M, Koch T. Anonymous critical incident reporting system in anaesthesiology. Results after 18 months (German) Anaesthesist. 2006;55:133–141. doi: 10.1007/s00101-005-0926-y.
    1. Schnabel A, Meyer-Frieβem CH, Zahn PK, Pogatzki-Zahn EM. Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials. Br J Anaesth. 2013;111:564–572. doi: 10.1093/bja/aet196.
    1. Meyer-Massetti C, Conen D. Assessment, frequency, causes, and prevention of medication errors - a critical analysis (German) Ther Umsch. 2012;69:347–352. doi: 10.1024/0040-5930/a000296.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere