Critical Incident Reporting in Anaesthesiology in Switzerland using Standard Internet Technology

S. Staender MD, M. Kaufman MD, D. Scheidegger MD

Department of Anaesthesia, University of Basel, Kantonsspital, CH-4031 Basel, Switzerland

Keywords: complications, incident reporting, anaesthesia

Voluntary incident reporting can be one tool to detect safety deficits in anaesthesiology. Using standard Internet technology, we set up a registry for critical events in the anaesthetic domain in Switzerland. Human error was the leading course of error. On the other hand, human performance, like knowledge, skill, experience and situational awareness helped to prevent a critical incident to proceed to an accident.

If we accept the fact that failures exist in everyday practice in hospitals we need to decide which method to choose to investigate these errors. Existing methods for error detection include: direct observation, chart reviews and/or computer screening, focus groups and incident reporting (ref. 1). All of them have advantages and disadvantages.

Voluntary reporting of critical events is another means to gain insight into dangerous situations.

The advantages of incident reporting are:

• Incidents happen far more often than severe accidents. Therefore, analysing incidents provides a far broader database in a certain amount of time.
• The analysis of incidents gives the opportunity to look for recoveries out of dangerous situations. Such analyses cannot be carried out as with accidents, simply because there is no recovery.
• Incident analysis can (under certain conditions) lead to root-causes of errors. These detected root-causes can then form the basis of very strong quality-improvement actions.
• Tracking incidents allows a monitoring of the quality of the structure and process of certain endeavours over time and over change in policies, if compliance is high.
• Exchanging experiences on critical events has a strong teaching potential even for old professionals, thus empowering people and teams.
• COSTS ! are low compared to other means as long as you are not having such a large, national organisation as the Aviation Safety Reporting System (ASRS) in the United States with a yearly budget of two million dollars. On a local level, incident reporting probably is good value for money when you keep in mind, that the patient care costs of a preventable adverse drug event were calculated at more than 4000 dollars (ref. 2).

At the Department of Anaesthesia at the University of Basel, Switzerland we have therefore set up an anonymous critical incident reporting system (CIRSÓ ) for anaesthetists in 1996 based on standard Internet technology (ref. 3).

CIRSÓ is implemented on the local network using Internet technology. Against the Internet it is protected with a firewall that satisfies the strong legal requirements of the national data-security act. In the hospital, CIRSÓ can be reached from every networked computer. Computers are located in the offices, the theatre, the recovery room and the intensive care unit. Therefore, participating in CIRSÓ is possible from very different locations within the hospital. CIRSÓ is completely electronic. From a typical Internet page, several local links are possible: links to background information about the project, links to the questionnaire, links to already reported cases and links to extraordinary cases with a high teaching potential. The content of the detailed questionnaire (HTML-form) is automatically inserted into a central database (MS-ACCESSÒ ). This database provides the users with the above mentioned details of every case and allows an easy compilation of the data. Furthermore, with the help of a kind of dynamic, database driven bulletin-board, an anonymous discussion of each case is possible.

CIRSÓ is now in its third year and we have already received some 200 cases. Analysing 132 critical incidents showed that in 64% of the cases, human factors such as tiredness, haste, wrong decision making and reduced situational awareness contributed to the incident. Adding the factor of problems in team performance, namely insufficient communication, increases the rate to 83%. On the other hand, human performance like experience, skills and situational awareness prevented in 75% of the cases an incident to procced to an accident.

Since the end of 1998 we have also used this system as a tool for a national incident survey in anaesthesiology in Switzerland (CIRSÓ -CH). This national system is under the auspices of the national society of anaesthesiology (SGAR) in order to facilitate reporting. Again, this system, also running on the Internet, is accessible only in a protected way after an individual login procedure. Therefore it cannot be visited from outside. A national board of experts from different regions of Switzerland and different classes of hospitals maintains this system, publishes the national results and acts as a facilitator for expert-opinion on selected cases. This feedback on individual cases was regarded as most important for national success. It is worth noting, that the analysis and comments on the events require at least as much expertise as is involved in their generation. Furthermore, an international version of CIRSÓ exists, that is very similar to the local and national system. The unprotected international version of CIRSÓ is free available on the Internet at: http://www.medana.unibas.ch/cirs/. This Internet-site offers insights into this system.

CIRSÓ is regularly scanned for certain extremely important cases that would require immediate action. Then, from time to time, summary statistics are performed and the findings published. An analysis of underlying error-causes can be done on the local level, where sufficient information about the system is available. On the national level, this root-cause analysis is not possible, simply because of the anonymity of the system and the limited amount of details in the questionnaire about the unit and environment the reporter works in. Nevertheless, we believe that the national exchange of information on critical events enhances patient safety in Switzerland.

Underreporting and the lack of an appropriate denominator is for sure a major handicap of voluntary reporting systems. There is evidence that we still face a huge underreporting of critical incidents. Another problem with the anonymous character of such an incident reporting systems lies in the impossibility to validate the submitted information and the possible bias of reporters using such systems. First, there can be some uncertainty about who is reporting and what gets reported. Knowing the outcome of a certain case can also influence both the reporter and the analyst. Keeping these limitations in mind, we nevertheless believe that certain trends can be detected from voluntary and anonymously reported critical incidents which can be used as the basis for action to improve safety.

S. Staender MD, staff anaesthesiologist, Department of Anaesthesia, University of Basel, Kantonsspital, CH-4031 Basel, Switzerland. Telephone: ++41 (61) 265 2525, Facs: ++41 (61) 265 7320