Anaesthesia and perioperative incident reporting systems: Opportunities and challenges

被引:15
作者
Arnal-Velasco, Daniel [1 ]
Barach, Paul [2 ,3 ]
机构
[1] Hosp Univ Fundac Alcorcon, Dept Anaesthesiol, Madrid, Spain
[2] Wayne State Univ, Sch Med, Childrens Hosp, Detroit, MI 48202 USA
[3] Jefferson Coll Populat Hlth, Philadelphia, PA USA
关键词
patient safety; incident reporting; safety culture; adverse event; near miss; learning systems; PATIENT SAFETY; HELSINKI DECLARATION; LEARNING-SYSTEM; ERROR; PERCEPTIONS; EXPERIENCE; CULTURE; MISHAPS; EVENTS; CLAIMS;
D O I
10.1016/j.bpa.2020.04.013
中图分类号
R614 [麻醉学];
学科分类号
100217 ;
摘要
Incident Reporting Systems (IRS) continue to be an important in-fluence on improving patient safety. IRS can provide valuable in-sights into how to prevent patients from being harmed at the organizational level. But inadequate expectations and misuse, for performance assessment, patient safety measurement or research, have hindered the full IRS potential. Health care organizations need to develop effective strategies built on trust and truth telling to improve the impact of IRS. This requires strategies to address the limited resources to analyse the near-misses or adverse events; avoid the punitive drift through maintaining the anonymity and protective legislation; integrating IRS and avoiding its confusion with mandatory adverse event response systems; training data analysts to focus on the system instead of the individual through a balanced simple taxonomy; combine the analyses at the local level, to reinforce effective and personalized feedback, with the potential of a national or supranational learning platform. (c) 2020 Elsevier Ltd. All rights reserved.
引用
收藏
页码:93 / 103
页数:11
相关论文
共 76 条
[1]  
[Anonymous], 2006, Resilience Engineering
[2]  
Arnal D, 2011, REV ESP ANESTESIOL R, V58, pS22
[3]   Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008 [J].
Arnot-Smith, J. ;
Smith, A. F. .
ANAESTHESIA, 2010, 65 (11) :1106-1113
[4]  
Bagian J P, 2001, Jt Comm J Qual Improv, V27, P522
[5]   Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems [J].
Barach, P ;
Small, SD .
BMJ-BRITISH MEDICAL JOURNAL, 2000, 320 (7237) :759-763
[6]  
Battles JB, 1998, ARCH PATHOL LAB MED, V122, P231
[7]   A STUDY OF THE DEATHS ASSOCIATED WITH ANESTHESIA AND SURGERY - BASED ON A STUDY OF 599,548 ANESTHESIAS IN 10 INSTITUTIONS 1948-1952, INCLUSIVE [J].
BEECHER, HK ;
TODD, DP .
ANNALS OF SURGERY, 1954, 140 (01) :2-34
[8]   Continuous improvement of safety in the Intensive Care and Surgical environment according to UNE 179003:2013 standard: 8 years experience [J].
Cabadas Avion, R. ;
Leal Ruiloba, M. S. ;
Munoz Mella, M. A. ;
Vazquez Lima, A. ;
Ojea Cendon, M. ;
Enriquez de Salamanca, I. .
REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION, 2018, 65 (09) :486-494
[9]   Patient and Family Involvement Disclosing Adverse Events to Patients [J].
Cantor, Michael D. ;
Barach, Paul ;
Derse, Arthur ;
Maklan, Claire W. ;
Wlody, Ginger Schafer ;
Fox, Ellen .
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY, 2005, 31 (01) :5-12
[10]   Balancing clinical team perceptions of the workplace: Applying 'work domain analysis' to pediatric cardiac care [J].
Cassin, Bryce R. ;
Barach, Paul R. .
PROGRESS IN PEDIATRIC CARDIOLOGY, 2012, 33 (01) :25-32