Implementation of a Critical Incident Reporting System in a Neurosurgical Department

Abstract

Background: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Key words

critical incident - reporting system - safety gap

References

• 1  . Bundesministerium für Gesundheit. Aktionsplan 2008/2009 zur Verbesserung der Arzneimitteltherapiesicherheit (AMTS) in Deutschland.  www.ap-amts.de [last accessed 11/20/2009]
• 2 Hoppe J. D.,, Schrappe M.,. Aktionsbündnis Patientensicherheit e. V. Aus Fehlern lernen.  www.gesundheits.de/bagp/BAGP-Dokumente/Aus_Fehlern_lernen.pdf [last accessed 11/20/2009]
• 3 Choy CY. Critical incident monitoring in anaesthesia.  Curr Opin Anaesthesiol. 2008;  21 183-186
• 4 Flanagan JC. The critical incident technique.  Psychol Bull. 1954;  51 327-358
• 5 Katz RI, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program.  Anesth Analg. 2000;  90 344-350
• 6 Haller U, Welti S, Haenggi D. et al . From the concept of guilt to the value-free notification of errors in medicine. Risks, errors and patient safety.  Gynakol Geburtshilfliche Rundsch. 2005;  45 147-160
• 7 Kobberling J. The critical incident reporting system (CIRS) as a measure to improve quality in medicine.  Med Klin (Munich). 2005;  100 143-148
• 8 Reissner P, Schnurrer JMM. Strategien zur Vermeidung von Risiken in der Arzneimitteltherapie.  Krankenhauspharmazie. 2008;  29 343-349
• 9 Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.  Med Care. 2007;  45 997-1002
• 10 Grant MJ, Donaldson AE, Larsen GY. The safety culture in a children's hospital.  J Nurs Care Qual. 2006;  21 223-229
• 11 Wu AW, Pronovost P, Morlock L. ICU incident reporting systems.  J Crit Care. 2002;  17 86-94
• 12 Missbach-Kroll A, Nussbaumer P, Kuenz M. et al . First experience with a critical incident reporting system in surgery.  Chirurg. 2005;  76 868-874 discussion 875 
• 13 Hubler M, Mollemann A, Eberlein-Gonska M. et al . Anonymous critical incident reporting system in anaesthesiology. Results after 18 months.  Anaesthesist. 2006;  55 133-141
• 14 Dominguez Fernandez E, Kolios G, Schlosser K. et al . Introduction of a critical incident reporting system in a surgical university clinic. What can be achieved in a short term?.  Dtsch Med Wochenschr. 2008;  133 1229-1234
• 15 Brun A. Preliminary results of an anonymous internet-based reporting system for critical incidents in ambulatory primary care.  Ther Umsch. 2005;  62 175-178
• 16 Frey B, Buettiker V, Hug MI. et al . Does critical incident reporting contribute to medication error prevention?.  Eur J Pediatr. 2002;  161 594-599
• 17 Madzimbamuto FD, Chiware R. A critical incident reporting system in anaesthesia.  Cent Afr J Med. 2001;  47 243-247
• 18 Bartolome Ruibal A, Diaz-Canabate JI, Santa-Ursula Tolosa JA. et al . Application of a critical incident reporting and analysis system in an anesthesiology department.  Rev Esp Anestesiol Reanim. 2006;  53 471-478
• 19 Choy YC. Critical incident monitoring in anaesthesia.  Med J Malaysia. 2006;  61 577-585
• 20 Freestone L, Bolsin SN, Colson M. et al . Voluntary incident reporting by anaesthetic trainees in an Australian hospital.  Int J Qual Health Care. 2006;  18 452-457
• 21 Bowman L, Carlstedt BC, Black CD. Incidence of adverse drug reactions in adult medical inpatients.  Can J Hosp Pharm. 1994;  47 209-216
• 22 Wright M, Parker G. Incident monitoring in psychiatry.  J Qual Clin Pract. 1998;  18 249-261
• 23 Ahluwalia J, Marriott L. Critical incident reporting systems.  Semin Fetal Neonatal Med. 2005;  10 31-37
• 24 Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers.  Qual Saf Health Care. 2004;  13 ((Suppl 2)) ii3-9
• 25 Fox MA, Webb RK, Singleton R. et al . The Australian Incident Monitoring Study. The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports.  Anaesth Intensive Care. 1993;  21 646-649
• 26 Currie M, Mackay P, Morgan C. et al . The Australian Incident Monitoring Study. The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports.  Anaesth Intensive Care. 1993;  21 596-601
• 27 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
• 28 Thomas AN, Pilkington CE, Greer R. Critical incident reporting in UK intensive care units: a postal survey.  J Eval Clin Pract. 2003;  9 59-68
• 29 Reissner PSH, Tronnier V. Der Apotheker als Teil des therapeutischen Teams – Wunsch oder Realität?.  Krankenhauspharmazie. 2007;  5 6

Correspondence