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Original article

Vol. 151 No. 5152 (2021)

Critical incident reporting over time: a retrospective, descriptive analysis of 5493 cases

  • Christoph Jäger
  • Giulia Mohr
  • Ken Gökcimen
  • Alexander Navarini
  • René Schwendimann
  • Simon Müller
DOI
https://doi.org/10.4414/SMW.2021.w30098
Cite this as:
Swiss Med Wkly. 2021;151:w30098
Published
28.12.2021

Summary

PURPOSE: As recommended by the WHO and many national healthcare authorities, health care institutions of most industrialised countries have employed a critical incident reporting system (CIRS). However, little is known about differences in critical incidents across clinical specialties, the use of CIRSs amongst different professional groups, the types, severity and risk of reoccurrence of critical incidents, their contributing factors and the preventive actions taken in response.

METHODS: In this retrospective, descriptive study we critically reviewed all reports filed in the CIRS of our institution between 2013 and 2019 and analysed characteristics over time.

RESULTS: Of the 5493 analysed incidents, the main types were related to medications (32.8%), clinical procedures (32.6%) or behaviour of employees (23.3%). Only 21.6% of reports were made by physicians, 51.3% were rated at least “high risk”. Major contributing factors were personal factors (44.0%), lack of training and knowledge (43.7%) and communication errors (36.1%). Most actions taken to prevent similar events aimed at improving communications (23.6%); in 46.3% no actions whatsoever were taken. Longitudinal analysis revealed that reporting increased in internal medicine and obstetrics but collapsed in laboratory medicine / microbiology. Steady increases in medication-type incidents as well as lack of training and knowledge as contributing factors were observed.

CONCLUSION: This study revealed that the efferent loop (feedback, preventive actions taken) was the weakest part of the CIRS in our institution, indicating that no learning may have resulted from a large number of reports. In particular, the actions taken appeared to not adequately address the major contributing factors. This highlights that special attention must be paid to the efferent loop of a CIRS to fulfil the purpose of such a reporting system and ultimately to improve patient safety.

References

  1. World Health Organization. (2019). Patient safety - Global action on patient safety. Report by the Director-General. Geneva: World Health Organization 2019. https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_26-en.pdf. (accessed 2020 June 23)
  2. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019 Jul;366:l4185. https://doi.org/10.1136/bmj.l4185
  3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008 Jun;17(3):216–23. https://doi.org/10.1136/qshc.2007.023622
  4. Glossar Patientensicherheit. Definition und Begriffsbestimmungen. Ärztliches Zentrum für Qualität in der Medizin (äzq). http://www.aezq.de/mdb/edocs/pdf/patientensicherheit/glossar-patientensicherheit.pdf. Published 2005. (Accessed 2020 July 16)
  5. World Health Organization. (‎2005)‎. World alliance for patient safety: WHO draft guidelines for adverse event reporting and learning systems: from information to action. World Health Organization. https://apps.who.int/iris/handle/10665/69797
  6. Petschnig W, Haslinger-Baumann E. Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety. States Health. 2017;3(9):9. https://doi.org/10.1186/s40886-017-0060-y
  7. Bommersholdt ME. (2014). Wesentliche Erkenntnisse und Empfehlungen zu Melde- und Lernsystemen für Zwischenfälle auf dem Gebiet der Patientensicherheit in Europa. https://studylibde.com/doc/17369186/melde--und-lernsystemen-f%C3%BCr-zwischenf%C3%A4lle-auf-dem-gebiet-der. (accessed 2020 July 17)
  8. Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Qual Saf. 2016 Feb;25(2):92–9. https://doi.org/10.1136/bmjqs-2015-004405
  9. Leape LL. Reporting of adverse events. N Engl J Med. 2002 Nov;347(20):1633–8. https://doi.org/10.1056/NEJMNEJMhpr011493
  10. Niemeier M, Hamsen U, Yilmaz E, et al. Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems. Eur J Trauma Emerg Surg. 2019;•••: https://doi.org/10.1007/s00068-019-01128-y; Advance online publication.
  11. Findlay Ú, Best H, Ottrey M. Improving patient safety in radiotherapy through error reporting and analysis. Radiography. 2016;22(1):3–11. https://doi.org/10.1016/j.radi.2016.10.009
  12. Luebke J, Lang SJ, Reinhard T. Das Critical Incident Reporting System im Risikomanagement der Klinik für Augenheilkunde in Freiburg [Critical Incident Reporting System in Risk Management at the Eye Center in Freiburg]. Klin Monatsbl Augenheilkd. 2017 Jul;234(7):894–9. https://doi.org/10.1055/s-0043-110570
  13. Forster AJ, Fung I, Caughey S, Oppenheimer L, Beach C, Shojania KG, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006 Nov;108(5):1073–83. https://doi.org/10.1097/01.AOG.0000242565.28432.7c
  14. Aaronson EL, Brown D, Benzer T, Natsui S, Mort E. Incident Reporting in Emergency Medicine: A Thematic Analysis of Events. J Patient Saf. 2019 Dec;15(4):e60–3. https://doi.org/10.1097/PTS.0000000000000399
  15. Mueller SM, Mohr G, Navarini AA, Gantenbein L, Goldust M, Karagaiah P, et al. Critical incidence reporting in dermatology: a cross-sectional study of 94 cases in a tertiary referral center. J Dermatolog Treat. 2020 Oct; 1–2. https://doi.org/10.1080/09546634.2020.1839005
  16. Staender S, Davies J, Helmreich B, Sexton B, Kaufmann M. The anaesthesia critical incident reporting system: an experience based database. Int J Med Inform. 1997 Nov;47(1-2):87–90. https://doi.org/10.1016/S1386-5056(97)00087-7
  17. National Patient Safety Agency NHS. (2008). A risk matrix for risk managers. https://www.neas.nhs.uk/media/118673/foi.16.170_-_risk_matrix_for_risk_managers_v91.pdf. (accessed 2020 June 23 2020)
  18. World Health Organization. (2009). Conceptual framework for the international classification for patient safety (ICPS); Version 1.1 Final Technical Report. http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf. (accessed 2020 June 27)
  19. Neuhaus C, Holzschuh M, Lichtenstern C, St Pierre M. Erkenntnisse aus 10 Jahren CIRS‑AINS : Eine Analyse von Nutzerverhalten und Ausblick auf neue Herausforderungen [Findings from 10 years of CIRS-AINS: An analysis of usepatterns and insights into new challenges] [published online ahead of print, 2020 Aug 17]. Anaesthesist. 2020 Nov;69(11):793–802. https://doi.org/10.1007/s00101-020-00829-z
  20. Marra AR, Algwizani A, Alzunitan M, Brennan TM, Edmond MB. Descriptive Epidemiology of Safety Events at an Academic Medical Center. Int J Environ Res Public Health. 2020 Jan;17(1):353. https://doi.org/10.3390/ijerph17010353
  21. Burlison JD, Quillivan RR, Kath LM, Zhou Y, Courtney SC, Cheng C, et al. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting. J Patient Saf. 2020 Sep;16(3):187–93. https://doi.org/10.1097/PTS.0000000000000336
  22. Sendlhofer G, Schweppe P, Sprincnik U, Gombotz V, Leitgeb K, Tiefenbacher P, et al. Deployment of Critical Incident Reporting System (CIRS) in public Styrian hospitals: a five year perspective. BMC Health Serv Res. 2019 Jun;19(1):412. https://doi.org/10.1186/s12913-019-4265-0
  23. Hubertus J, Piehlmeier W, Heinrich M. Communicating the Improvements Developed from Critical Incident Reports is an Essential Part of CIRS. Klin Padiatr. 2016 Sep;228(5):270–4. https://doi.org/10.1055/s-0042-113311
  24. Bodina A, Demarchi A, Castaldi S. A web-based incident reporting system: a two years’ experience in an Italian research and teaching hospital. Annali di igieni 2014;26(3):219-25.
  25. Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review. BMC Health Serv Res. 2018 Jul;18(1):521. https://doi.org/10.1186/s12913-018-3335-z
  26. Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016 Feb;25(2):71–5. https://doi.org/10.1136/bmjqs-2015-004732
  27. Ahlberg EL, Elfström J, Borgstedt MR, Öhrn A, Andersson C, Sjödahl R, et al. Learning From Incident Reporting? Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care. J Patient Saf. 2020 Dec;16(4):264–8. https://doi.org/10.1097/PTS.0000000000000343