Staender S, Davies J, Helmreich B, Sexton B, Kaufmann M
University of Basel, Department of Anaesthesia, Kantonsspital, Switzerland.
Int J Med Inform. 1997 Nov;47(1-2):87-90. doi: 10.1016/s1386-5056(97)00087-7.
To date there have been fewer than a dozen studies on the nature of, and contributory factors in, critical incidents (CI) in anaesthesia. The first of these, by Cooper and colleagues, showed that the vast majority of their CI involved human error [1]. Most recently, the on-going Australian Incident Monitoring Study (AIMS), with now more than 2000 reports, has shows that aspects of 'system failure' may constitute the bulk of the contributory factors, even though some human error may be detected in about 80% of the analysed cases [2]. We set up a Critical Incident Reporting System (CIRS) to collect anonymous CI in anaesthesia using a reporting form on the Internet. CIRS analysis of the first 60 cases corroborates the findings of previous CI studies. In addition, our preliminary results have shown certain important trends, especially those concerning the contributory factor of communication in the Operating Theatre. Although to date we are unable to assess the educational importance of these CI reports, we believe that there is great potential for this aspect of CIRS.
迄今为止，关于麻醉术中危急事件（CI）的性质及促成因素的研究不足一打。其中第一项研究由库珀及其同事开展，结果显示他们所研究的危急事件绝大多数都涉及人为失误[1]。最近，正在进行的澳大利亚事件监测研究（AIMS）已收到2000多份报告，结果表明，“系统故障”方面可能构成促成因素的主要部分，尽管在约80%的分析病例中可能会发现一些人为失误[2]。我们建立了一个危急事件报告系统（CIRS），通过互联网上的报告表格收集麻醉术中的匿名危急事件。对前60例病例的CIRS分析证实了以往危急事件研究的结果。此外，我们的初步结果显示了某些重要趋势，尤其是与手术室沟通促成因素有关的趋势。虽然迄今为止我们无法评估这些危急事件报告的教育意义，但我们认为CIRS的这一方面具有巨大潜力。
