Critical Incident Reporting
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1 Critical Incident Reporting Sven Staender, MD Chairman EBA/ESA Task Force Patient Safety Department of Anaesthesia and Intensive Care, Regional Hospital, Maennedorf/ Zuerich, Switzerland; CEEA 2012 Kosice
2
3 Outline o Basics o Practical Aspects of Application o Analysis Disclosure: Chairman of the EBA/ESA Taks Force Patient Safety without personal funding. No conflicts of interest, no industry support.
4 Do you make mistakes?
5 We take risk in private life...
6 ... as well as on the job!
7 Various Methods for Safety Analysis Incidence 1 : 10 High number of events 1 : : Low number of events 1 : : Very low number of events 1 : : Classical epidemiological tools High statistical power Local studies No events Reporting systems National or international studies Risk and accident modelling FMEA
8 ASRS
9 Aviation Safety Reporting System
10
11 Oops, oh sorry. That was a body lotion...!
12
13 Critical Incident Reporting System
14 Incident Reporting in Anaesthesia Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System Catchpole K, Bell MD, Johnson S. The incident reporting database at the National Patient Safety Agency 12,606 reports over a 2-year period 22.5% resulted in little harm or a moderate degree of harm 2.1% resulted in severe harm or death procedure or treatment problems generating the highest risk Anaesthesia Apr;63(4):340-6.
15 Cost of critical incidents in ICU Academic, tertiary care urban hospital Costs Medical ICU Cardiac Care Unit Per Patient Per Year 3,961 $ 3,857 $ 853,000 $ 630,000 $ Kaushal R et.al. Crit Care Med 2007;35:
16 What exactly are Critical Incidents?
17 Hazard vs. incident
18 Critical incident??
19 Critical incident!!!
20 Critical event Occurrence Error Side effect Event Deviation Complication Critical Incident Near miss Adverse Event
21 Organisation, Rules Normal state (Software) Technique (Hardware) Error Danger. Situation Non-Routine- Patient Near Miss Yes Operations Defences? (instituted, passiv) Algorithms, SOP s, Technique... No Yes (Environment) Critical Incident Recoveries? (creative, activ) Human, Team, Communication No (Lifeware) Accident
22 The Heinrich ratio Major injury Minor injury No injury accidents (Incidents) Heinrich HW. Industrial Accident Prevention: A Scientific Approach. New York, London 1941
23 Development of CIRS and CIRRNET
24 Systems in use Local Dep. Anaesth. Basel 1995 International CIRS (Internet) 1995 National CIRS of SSAR 1998 CIRRNET 2006
25 The challenge 2005
26 CIRRNET Critical Incident Reporting and Reacting NETwork
27 CIRRNET - Approach Data-Extraction from local incident systems (Defined minimal data set) Pooling of these incidents nationally Learning by distribution of individual cases Detection of hot spots Analysis / Synthesis by experts from anaesthesiology Recommendations ( Quick-Alerts )
28 CIRRNET Organisation of project CIRS CIRS CIRS CIRS Hsp. 1 Hsp. 2 Hsp. 3 Hsp. n MDS MDS MDS MDS Network-Management Data-Filing Steering Comm. WG 1 WG 2 WG n Recommendations
29 CIRRNET & Closed Claims analysis group 198 years of experience in anaesthesiology Chr. Kindler Beat Meister Thierry Girard Ph. Schumacher Frank Stüber Th. Schnider Martin Tramer S. Staender
30 Examples
31 Pattern recognition Audtls can eisaly raed a txet eevn wehn olny the frist and lsat chracater of a wrod are in its cerorct psoition.
32 Pattern recognition Look-alike drugs:
33 Case 1 10-years old boy for minor urologic procedure I.v. Induction without problems LMA placement easy Difficulties with ventilation
34 Case 1 10-years old boy for minor urologic procedure I.v. Induction without problems LMA placement easy Difficulties with ventilation Removal of the LMA Chewing gum on the tip of the LMA
35 Children love chewing gum...
36 Some animals, too...
37 Case 2 4 years old child for hernial repair Uneventful general anaesthesia In RCR empty 20 cc syringe to play with The child is already very much awake and watches the RCR-nurse doing her job...
38 Case 2
39 Case 3 CVC insertion planned Known allergy to iodine desinfectants Clear alcoholic desinfectant chosen and inserted in one bowl Lidocain in the other bowl After the first few cc s of Lidocain severe local pain...
40 Case 3
41 Conditions for Incident Reporting Voluntary Anonymous No punishment / blamefree Easy to use Feedback of information
42 Strenghts of Incident Reporting Number compared with accidents Root causes Training potential Recoveries Cost!! /
43 Weaknesses of Incident Reporting Underreporting Bias No Risk-Controlling tool Analysis
44 Analysis of Critical Incidents What does such an analysis of an incident datapool mean? Frequency of Critical Incidents Medication incident Technical event Communication event Organisational event Hygiene incidents Other 30 % 10 % 20 % 20 % 10 % 10 %
45 Analysis of Critical Incidents What do such numbers on a hospital level mean? Number of Critical Incidents reported per year Hospital A Hospital B Hospital C
46 Analysis of Critical Incidents Threat? Risk? Safety? Reporting Compliance?
47 Analysis of Critical Incidents Open questions: - Which cases will NOT be reported? - How many cases happen at all? per day? per unit? per hospital?
48 Counting Incidents is a waste of time. Charles Billings Former president of the Aeromedical Space Association
49 Learning through analysis
50 Who is guilty?
51 The Front-end operator? The user? The innocent bystander? The technique? Courtesy Marcus Rall, Tübingen The contractor?
52 Which cases?
53 Which Cases? Single Cases! PDCA - Cycle Risk-Likelyhood Ratio Case Collection Standard Process 1. Local Significance 2. General Importance e.g. Quick Alerts
54 Which Cases? Single Cases! PDCA - Cycle Risk-Likelyhood Ratio Case Collection Standard Process 1. Local Significance 2. General Importance e.g. Quick Alerts
55 Improvement cycle acc. PDCA (Plan Do Check Act)
56 Which Cases? Single Cases! PDCA - Cycle Risk-Likelyhood Ratio Case Collection Standard Process 1. Local Significance 2. General Importance e.g. Quick Alerts
57 Case clustering Wahrscheinlichkeit sehr hoch wahrscheinlich 5 hoch wahrscheinlich 4 wahrscheinlich 3 1 unwahrscheinlich 2 1 sehr unwahrscheinlich minimal gering mässig bedeutend fatal 1 Konsequenz
58 Case clustering What is reported more than once? What is the most important? What is least accepted by patients / public? What is most easily fixed?
59 Which Cases? Single Cases! PDCA - Cycle Risk-Likelyhood Ratio Case Collection Standard Process 1. Local Significance 2. General Importance e.g. Quick Alerts
60 Standard Process
61 Standard Process Drug prescribed Transfer Prescription to Patient Charts Take drug out of stock Distribute to Stock Local Pharmacy Delivering to Ward Prepare Drug Plan for correct Patient Administer Drug
62 Standard Process Drug prescribed Transfer Prescription to Patient Charts 0034 Take drug out of stock Prepare Drug Distribute to Stock 0064 Local Pharmacy Delivering to Ward Plan for correct Patient Administer Drug
63 Which Cases? Single Cases! PDCA - Cycle Risk-Likelyhood Ratio Case Collection Standard Process 1. Local Significance 2. General Importance e.g. Quick Alerts
64 Recommendations ouf of Single Cases CIRRNET Netzwerktreffen
65 One single case can lead to significant change! CIRRNET Netzwerktreffen
66 From Reporting to Learning...
67 Simple recommendations 1 glas is enough
68 1 glas is enough...
69 Flyer Publications
70 Quick Alerts
71 Lessons learned
72 CIRRNET Lessons learned Legal Legal uncertainty Organisational accountability? Methodologic Focus on local systems CIRRNET as information-hub and hot-spot-detector Content Challenge: Heuristics for cluster-identification necessary Value of single cases: Quick alerts Policy-character of recommendations
73 Summary
74 What can we learn from Critical Incidents? Critical incidents... have a huge learning potential point on exisiting or emerging risks are collection of single cases (statistics make no sense) serve as a window to the system
75 Stop trembling! Simply tell me what happened...
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