Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
BMJ Open Qual. 2023 Dec 20;12(4):e002389. doi: 10.1136/bmjoq-2023-002389.
Reporting adverse clinical events is essential to a culture of safety in healthcare. However, self-reporting such events is generally not widely prevalent in a typical academic anaesthesia department.
We set out to create a self-reporting tool to securely accept data from multiple anaesthesia service locations, including data linked to our electronic anaesthesia record, and combine them into an accessible database.We created a web-based database module for incident reporting integrated into the department's intranet. The system was also designed to actively prompt anaesthesia providers for reports following each day of clinical work.
478 events were recorded in the database in the first year of implementation. There were 33 347 anaesthesia encounters in that period, translating to a reporting rate of 1.43% (95% CI 1.31% to 1.57%). In the second year, which coincided with the second phase of implementation, 608 events were reported out of 45 985 anaesthesia encounters, for a reporting rate of 1.32% (95% CI 1.22% to 1.43%). Approximately 40% of events entered into the database occurred in a non-operating room location. The annual reporting rates for 2014, 2015, 2016, 2017, 2018 and 2019 were 1.26% (95% CI 1.16% to 1.37%), 1.15% (95% CI 1.05% to 1.25%), 1% (95% CI 0.9% to 1.1%), 0.6% (95% CI 0.53% to 0.68%), 0.5% (95% CI 0.44% to 0.57%), 0.4% (95% CI 0.3% to 0.5%), respectively.
Our incident reporting system facilitated reporting of events within and outside the operating room. The system captured event data valid for quality improvement within the anaesthesia department.
在医疗保健领域，报告不良临床事件对于安全文化至关重要。然而，在典型的学术麻醉科中，这种自我报告通常并不普遍。
我们着手创建一个自我报告工具，以安全地从多个麻醉服务地点接收数据，包括与我们的电子麻醉记录相关的数据，并将其合并到一个可访问的数据库中。我们创建了一个基于网络的数据库模块，用于将事件报告集成到部门的内部网中。该系统还设计为在每个临床工作日后主动提示麻醉提供者进行报告。
在实施的第一年，数据库中记录了 478 起事件。在此期间，有 33347 次麻醉手术，报告率为 1.43%（95%CI 1.31%至 1.57%）。在第二年，即实施的第二阶段，有 608 起事件在 45985 次麻醉手术中报告，报告率为 1.32%（95%CI 1.22%至 1.43%）。大约 40%的事件发生在非手术室地点。2014 年、2015 年、2016 年、2017 年、2018 年和 2019 年的年报告率分别为 1.26%（95%CI 1.16%至 1.37%）、1.15%（95%CI 1.05%至 1.25%）、1%（95%CI 0.9%至 1.1%）、0.6%（95%CI 0.53%至 0.68%）、0.5%（95%CI 0.44%至 0.57%）、0.4%（95%CI 0.3%至 0.5%）。
我们的事件报告系统促进了手术室内外事件的报告。该系统捕获了适用于麻醉科质量改进的事件数据。
