International Journal for Quality in Health Care Advance Access originally published online on October 19, 2006
International Journal for Quality in Health Care 2006 18(6):452-457; doi:10.1093/intqhc/mzl054
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Voluntary incident reporting by anaesthetic trainees in an Australian hospital
Department of Anaesthesia, The Geelong Hospital, Geelong, Victoria, Australia
Objective. To assess the reporting of critical incidents by anaesthetic trainees using personal digital assistants. The project also identified the reporting of ‘near miss’ incidents by anaesthetic trainees.
Design. Comparison of electronic incident reporting with retrospective case note review of cases in which no incident was reported.
Setting. A 400-bed university teaching hospital in Victoria.
Participants. Fourteen accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their training supervisors.
Interventions. Registrars and supervisors underwent initial training for 1 hour and were provided with ongoing support. The cases and incidents reported to the database using the portable digital assistants were analysed.
Main outcome measures. These were the total number of anaesthetics reported to the database; the number of incidents reported to the database; the outcome severity of incidents reported; and the number of incidents detected in the case note review that were not reported to the database.
Results. An incident was reported for 156 (3.5%) of 4441 anaesthetic procedures reported to the database. Of these incidents, 72 (46.2%) were ‘near misses’. One incident was identified in a review of 208 case notes, which had no incidents reported electronically, and was not reported to the database electronically. This gives a reporting rate of 99.52% [95% confidence interval (CI) 96.9–100%].
Conclusions. ANZCA trainees in routine anaesthetic practice can reliably use mobile computing technology to report critical incidents and ‘near miss’ incident data.
Keywords: adverse events, anaesthesia, critical incidents
Address reprint requests to Stephen N. Bolsin, Department of Anaesthesia, The Geelong Hospital, Geelong, Victoria, Australia. E-mail: steveb{at}barwonhealth.org.au
Accepted for publication September 17, 2006.