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: 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. · 0.56 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; · 1.91 Impact Factor
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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; · 1.34 Impact Factor