Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.

Autor:	Pedersen TH; Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark., Nabecker S; Department of Anesthesiology and Pain Management, Sinai Health System, University of Toronto, Toronto, ON, Canada. Electronic address: sabine.nabecker@sinaihealth.ca., Greif R; University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria., Theiler L; Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland., Kleine-Brueggeney M; Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
Jazyk:	angličtina
Zdroj:	British journal of anaesthesia [Br J Anaesth] 2024 Aug; Vol. 133 (2), pp. 371-379. Date of Electronic Publication: 2024 Jun 12.
DOI:	10.1016/j.bja.2024.04.052
Abstrakt:	Background: Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. Methods: This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. Results: Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. Conclusions: Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system. (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)
Databáze:	MEDLINE
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