McSoley Joseph William, Buck David Winthrop, Winterberg Abby V
Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
BMJ Open Qual. 2024 Dec 27;13(4):e002787. doi: 10.1136/bmjoq-2024-002787.
There is an under-reporting of anaesthesia-related safety events. Incident-capturing systems (ICSs) are essential for patient safety monitoring, identifying risks and ongoing opportunities for improvement. After a literature review and assessment of our current ICSs, we concluded that our institution lacked a reliable anaesthesia-specific ICS system, leading to under-reporting of anaesthesia-related safety events.
We conducted a quality improvement initiative to help increase perioperative safety event reporting by anaesthesiologists, fellows and certified registered nurse anaesthetists. We analysed all anaesthesia-related perioperative safety events from July 2019 to December 2020 to determine a baseline rate of safety events captured. We conducted a simplified failure-mode effects analysis and designed a key driver diagram to guide our initiative. Based on these, we designed and implemented seven interventions aimed at increasing anaesthesia-related perioperative safety event reporting. We then reviewed perioperative safety events captured from January 2021 to February 2023 and compared the safety event capture rate to baseline.
Over 10 months, we trialled and implemented multiple interventions aimed at increasing perioperative anaesthesia-related safety event capture, including re-education, strategic placement of report forms, education of anaesthesia and non-anaesthesia personnel, celebration of events captured, promotion of a safe-capture culture where reporting was not seen as punitive and the transition to an online anaesthesia ICS. Over 25 months, we demonstrated a sustained increase in event reporting from a baseline of 1.9 incidents captured per week (average of 1000 cases performed weekly) to 19 events captured per week postinterventions.
Increasing event reporting required a multifaceted approach-ongoing attention to reporting barriers and developing targeted interventions promoting sustained reporting. Education on the importance of reporting, creating a reliable electronic ICS, creating a non-punitive culture and continuing to promote a safety culture contributed to system improvement.
与麻醉相关的安全事件存在报告不足的情况。事件捕获系统（ICSs）对于患者安全监测、识别风险以及持续改进的机会至关重要。在对我们当前的ICSs进行文献综述和评估后，我们得出结论，我们的机构缺乏可靠的麻醉专用ICS系统，导致与麻醉相关的安全事件报告不足。
我们开展了一项质量改进计划，以帮助增加麻醉医生、住院医师和注册护士麻醉师对围手术期安全事件的报告。我们分析了2019年7月至2020年12月期间所有与麻醉相关的围手术期安全事件，以确定捕获的安全事件基线率。我们进行了简化的失效模式影响分析，并设计了关键驱动因素图来指导我们的计划。基于此，我们设计并实施了七项干预措施，旨在增加与麻醉相关的围手术期安全事件报告。然后，我们回顾了2021年1月至2023年2月期间捕获的围手术期安全事件，并将安全事件捕获率与基线进行了比较。
在10个月的时间里，我们试验并实施了多项旨在增加围手术期与麻醉相关安全事件捕获的干预措施，包括再教育、报告表格的战略放置、对麻醉和非麻醉人员的教育、对捕获事件的表彰、促进一种安全捕获文化，即报告不被视为惩罚性措施，以及向在线麻醉ICS的转变。在25个月的时间里，我们证明事件报告持续增加，从基线时每周捕获1.9起事件（每周平均进行1000例手术）增加到干预后每周捕获19起事件。
增加事件报告需要多方面的方法——持续关注报告障碍并制定有针对性的干预措施以促进持续报告。关于报告重要性的教育、创建可靠的电子ICS、营造非惩罚性文化以及持续促进安全文化有助于系统改进。
