6th Grazer Risk Day: The Future of Yesterday in Healthcare

摘要

BackgroundWithin our organization the critical incident reporting system (CIRS)was introduced in 2013. Since then, only limited use can be recognizedin terms of how many CIRS-cases were reported to the onlineavailablesystem. Reasons for underreporting are divers, however,dominantly it’s the fear of healthcare workers (HCW) whether theanonymity of the reporting employee is preserved. Consequently, weanalyzed CIRS-publication data from 2013 to 2017 in order to interpretthe development of CIRS in a tertiary university hospital.Material and methodsBased on reported CIRS-cases since the introduction of the onlineavailablesystem, data were analyzed according to the total numberof reported CIRS-cases, who reported a CIRS-case, which specialtyused CIRS and finally what kind of risk was reported most often. Wealso distinguished if the reported CIRS-case was in term of our definitiona correct CIRS-case or a so-called near miss (relevant for employeesafety) or if it was a patient harm.ResultsIn total 683 cases were reported into the CIRS, of which only 283 hadbeen a correct CIRS-case. 400 cases had been no CIRS or near misscase. Predominantly, CIRS-cases concerning surgical processes werereported (16%), followed by CIRS-cases concerning medicinal products(16%) and CIRS-cases concerning medical devices (10%). It wasmore likely, that nurses reported into CIRS (44%) than by physicians(24%). 45% of all CIRS-cases were reported by surgical disciplines,21% by interdisciplinary organization, 16% by non-surgical disciplinesand 13% came from anaesthesiology.ConclusionsA CIR-system is an essential component of clinical risk managementand is a simple tool that can be used to identify potential sources ofcritical incidents (1). CIRS can be a valuable instrument if CIRS is usedas foreseen. As CIRS is used just in rare situations according to thepresented data, CIRS should be introduced more comprehensively toconvince HCW that reporting into CIRS is safe and that any CIRS-casecan help to avoid future harm to patients.