Article type
Year
Abstract
Background: Incident reporting systems in medicine enable health care professionals to anonymously report patient safety incidents so that others can learn and patient safety can be strengthened. The German system, www.CIRS-AINS.de, is widely established in anesthesia and encompasses 1606 anesthesia-specific reports.
Objectives: Learning opportunities of individual reports can be published in case reports or alerts, but also in systematic evaluation. The method presented demonstrates the possibility to systematically analyze incident reports. Using the example of syringe pumps, reports were evaluated to show the risks of their use.
Methods: Titles of 1606 incident reports were searched by the term 'syringe pumpá (German 'Perfusorá), 54 reports were identified. The reports were classified according to the phase (A-D) of the medication process in which the incident originated. Within these phases 13 areas of risk were identified.
Results: Phase and area of risk. A. Prescribing: Discontinue medication when indicated; B. Transcribing/Documenting: Communication of prescription; C. Dispensing: Preparation of syringe for pump; D. Administering: Programming/labelling of syringe pump, Connection of lines, Lines intact, Power supply of syringe pump, Alarms of syringe pump, Change of syringe, Syringe pump works correctly, Syringe pumps and magnetic resonance imaging, Mounting of syringe pump; E. Monitoring: Monitoring of vital signs. The 13 areas of risk encompassed one to eight reports and exhibited different aspects within the area of risk.
Conclusions: Reports from incident reporting systems are one possibility to make experiences of individuals available for systematic learning. Because not all safety incidents are reported, data is not representative. The method presented can help-through summation of individual evidence- to systematically identify areas of risk during the medication process or within other areas of health care. The identified areas of risk can be used to develop strategies to diminish risk and strengthen patient safety.
Objectives: Learning opportunities of individual reports can be published in case reports or alerts, but also in systematic evaluation. The method presented demonstrates the possibility to systematically analyze incident reports. Using the example of syringe pumps, reports were evaluated to show the risks of their use.
Methods: Titles of 1606 incident reports were searched by the term 'syringe pumpá (German 'Perfusorá), 54 reports were identified. The reports were classified according to the phase (A-D) of the medication process in which the incident originated. Within these phases 13 areas of risk were identified.
Results: Phase and area of risk. A. Prescribing: Discontinue medication when indicated; B. Transcribing/Documenting: Communication of prescription; C. Dispensing: Preparation of syringe for pump; D. Administering: Programming/labelling of syringe pump, Connection of lines, Lines intact, Power supply of syringe pump, Alarms of syringe pump, Change of syringe, Syringe pump works correctly, Syringe pumps and magnetic resonance imaging, Mounting of syringe pump; E. Monitoring: Monitoring of vital signs. The 13 areas of risk encompassed one to eight reports and exhibited different aspects within the area of risk.
Conclusions: Reports from incident reporting systems are one possibility to make experiences of individuals available for systematic learning. Because not all safety incidents are reported, data is not representative. The method presented can help-through summation of individual evidence- to systematically identify areas of risk during the medication process or within other areas of health care. The identified areas of risk can be used to develop strategies to diminish risk and strengthen patient safety.