Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies.
All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety.
Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09).
Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments.
"Three studies used the Eindhoven error classification (Nast et al. 2005; Henneman et al. 2010; Rodrigues et al. 2011). The remainder involved variations mainly of the Reason classification, including simple classification like active failures or not, faulty information processing or cognitive or non-cognitive errors to more complex classifications including inattention, memory failure and confusion (Itoh, Omata, and Andersen 2007), or carelessness and distraction, poor assessment of the situation (Kantelhardt et al. 2011). Most studies simply described the occurrence of causal factors and error types by reporting of univariate results for the presence or not of individual factors and types. "
[Show abstract][Hide abstract] ABSTRACT: Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification. Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.
"In the future, a pilot study involving a small number of equine hospitals might be an option to test the appropriateness of a CIRS in equine anaesthesia , possibly as an integral part of a future CEPEF4 study. Several types of online documentation systems exist, with at least one being developed in collaboration with experts from flight safety (Kantelhardt et al. 2011). We came to the conclusion that critical incidents also happen in equine anaesthesia which require measures to be taken. "
[Show abstract][Hide abstract] ABSTRACT: To provide a brief introduction into Critical Incident Reporting Systems (CIRS) as used in human medicine, and to report the discussion from a recent panel meeting discussion with 23 equine anaesthetists in preparation for a new CEPEF-4 (Confidential Enquiry into Perioperative Equine Fatalities) study.
Moderated group discussions, and review of literature.
The first group discussion focused on the definition of 'preventable critical incidents' and/or 'near misses' in the context of equine anaesthesia. The second group discussion focused on categorizing critical incidents according to an established framework for analysing risk and safety in clinical medicine.
While critical incidents do occur in equine anaesthesia, no critical incident reporting system including systematic collection and analysis of critical incidents is in place.
Critical incident reporting systems could be used to improve safety in equine anaesthesia - in addition to other study types such as mortality studies.
"Complications are regularly discussed among faculty and, if considered helpful, neuroradiologists or other specialists. The introduction of critical incident monitoring, which is yet more frequently applied by anesthesiologist11), constituted a further step6). Regular meetings with specialists from other hospitals are not yet standard at NMU. "
[Show abstract][Hide abstract] ABSTRACT: The Department of Neurosurgery (DNS) of the Seoul National University Hospital (SNUH), belongs to the largest and oldest such institutions in Korea. Because of its growing reputation it is hardly surprising that the DNS draws visitor and scholars for clinical education and academic exchange from far beyond Korea. I myself visited the SNUH in February and March 2013. During this time I composed this evaluation in which I compare the DNS to my home Department at the Johannes Gutenberg-University in Mainz/Germany, as well as the situation of Neurosurgery in Korea and Germany in general. In the first part this evaluation summarizes data concerning equipment, staff and organizational structure, as well as educational and scientific issues of the DNS. In the second part some issues of interest are discussed in special regard to the corresponding practices in Germany.
Journal of Korean Neurosurgical Society 05/2013; 53(5):261-8. DOI:10.3340/jkns.2013.53.5.261 · 0.64 Impact Factor
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