Willcox Timothy W, Baker Robert A
Green Lane Cardiothoracic Unit, Auckland City Hospital, Auckland, New Zealand; and Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand.
Cardiac and Thoracic Surgery Unit, Flinders Medical Centre, Adelaide, South Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
J Extra Corpor Technol. 2020 Mar;52(1):7-12. doi: 10.1182/ject-1900030.
The Australia and New Zealand College of Perfusionists' (ANZCP) Perfusion Incident Reporting System was established in 1998 and has evolved to an open access on-line incident perfusion reporting system (PIRS-2). Changes were made to PIRS-2 to promote learning from what went well in unexpected situations. A 9-question survey was e-mailed to the PIRS-2 contact group to elicit feedback on attitudes to voluntarily reporting perfusion-related incidents and near-miss events to PIRS-2. In August 2019, a 9-question survey using SurveyMonkey (San Mateo Ca) was e-mailed to 198 perfusionists currently on the ANZCP PIRS-2 e-mail contacts group. Responses for all responding practicing perfusionists were totaled and expressed as a percentage of the total number of respondents. The respondents were then grouped by region and responses were expressed as a percentage of respondents from each region as well as for grouped responses from Australia/New Zealand (ANZ) and non-ANZ respondents. The response rate was 49.5% with 95 practicing perfusionists completing the survey. In the 12 months before the survey, 22% of respondents had submitted reports to PIRS-2, whereas 79% had read e-mailed reports. Unit culture was the most frequently cited barrier to reporting from all respondents (19%; 0% to 40% by region). Twenty-five percentage of Australian respondents cited unit culture as a barrier to reporting vs. 0% of New Zealand respondents. A combination of concern of discovery and identification of region ranked second as a barrier for 17% of all respondents. The open access ANZCP PIRS-2 voluntary incident reporting in perfusion was widely viewed as relevant and beneficial to both individual practice and to team performance. A high likelihood to considering reporting incidents is tempered by the well-established barriers of ease of the reporting system, the fix and forget phenomenon, concerns of discovery, and a defensive unit culture.
澳大利亚和新西兰灌注师学院（ANZCP）的灌注事件报告系统于1998年建立，现已发展成为一个开放获取的在线事件灌注报告系统（PIRS-2）。对PIRS-2进行了改进，以促进从意外情况中进展顺利的方面进行学习。通过电子邮件向PIRS-2联系小组发送了一份包含9个问题的调查问卷，以征集关于向PIRS-2自愿报告灌注相关事件和未遂事件态度的反馈。2019年8月，使用SurveyMonkey（加利福尼亚州圣马特奥）的一份包含9个问题的调查问卷通过电子邮件发送给了目前在ANZCP PIRS-2电子邮件联系小组中的198名灌注师。对所有回复的执业灌注师的回答进行汇总，并表示为总回复人数的百分比。然后按地区对受访者进行分组，回答表示为每个地区受访者的百分比以及澳大利亚/新西兰（ANZ）和非ANZ受访者的分组回答的百分比。回复率为49.5%，95名执业灌注师完成了调查。在调查前的12个月中，22%的受访者向PIRS-2提交了报告，而79%的受访者阅读了电子邮件报告。单位文化是所有受访者中最常被提及的报告障碍（19%；各地区为0%至40%）。25%的澳大利亚受访者将单位文化视为报告障碍，而新西兰受访者这一比例为0%。对发现和地区识别的担忧综合起来在所有受访者中位列第二，占17%。开放获取的ANZCP PIRS-2灌注自愿事件报告被广泛认为对个人实践和团队绩效都具有相关性和益处。报告系统的便利性、“一劳永逸”现象、对发现的担忧以及防御性的单位文化等既定障碍，削弱了考虑报告事件的高可能性。
