Implementation of a Critical Incident Reporting System in a Neurosurgical Department
ABSTRACT 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.
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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.Veterinary Anaesthesia and Analgesia 07/2013; 40(6). DOI:10.1111/vaa.12065 · 1.78 Impact Factor
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ABSTRACT: Object Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. Methods In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Results Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Conclusions Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.Neurosurgical FOCUS 11/2012; 33(5):E7. DOI:10.3171/2012.9.FOCUS12252 · 2.14 Impact Factor
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ABSTRACT: Background Patient safety culture is an important factor in the effort to reduce adverse events in the hospital and improve patient safety. A few studies have shown the relationship between patient safety culture and adverse events, yet no such research has been reported in China. Objectives This study aimed to describe nurses perception of patient safety culture and frequencies of adverse events, and examine the relationship between them. Design This study was a descriptive, correlated study. Setting and Participants: We selected 28 inpatient units and emergency departments in 7 level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463 nurses. Methods The Hospital Survey on Patient Safety Culture was used to measure nurses perception of patient safety culture, and the frequencies of adverse events which happened frequently in hospital were estimated by nurses. We used multiple logistic regression models to examine the relationship between patient safety culture scores and estimated frequencies of each type of adverse event. Results The positive response rates of 12 dimensions of the Hospital Survey on Patient Safety Culture varied from 23.6% to 89.7%. There were 47.8%-75.6% nurses who estimated that these adverse events had happened in the past year. After controlling for all nurse related factors, a higher mean score of “Organizational Learning-Continuous Improvement” was significantly related to lower the occurrence of pressure ulcers (OR = 0.249), prolonged physical restraint (OR = 0.406), and complaints (OR = 0.369); a higher mean score of “Frequency of Event Reporting” was significantly related to lower the occurrence of medicine errors (OR = 0.699) and pressure ulcers (OR = 0.639). Conclusions The results confirmed the hypothesis that an improvement in patient safety culture was related to a decrease in the occurrence of adverse events.International journal of nursing studies 01/2013; 51(8). DOI:10.1016/j.ijnurstu.2013.12.007 · 2.25 Impact Factor