Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.
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BORIS DOI
Publisher DOI
PubMed ID
38866639
Description
BACKGROUND
Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported.
METHODS
This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method.
RESULTS
Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers.
CONCLUSIONS
Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.
Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported.
METHODS
This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method.
RESULTS
Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers.
CONCLUSIONS
Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.
Date of Publication
2024-08
Publication Type
Article
Subject(s)
600 - Technology::610 - Medicine & health
Keyword(s)
airway management critical incident reporting near-miss patient safety qualitative study
Language(s)
en
Contributor(s)
Pedersen, Tina H | |
Nabecker, Sabine | |
Theiler, Lorenz | |
Kleine-Brueggeney, Maren |
Additional Credits
Emeriti, Medizinische Fakultät
Series
British journal of anaesthesia
Publisher
Elsevier
ISSN
1471-6771
Access(Rights)
open.access