1000 anaesthetic incidents: experience to date.
The anaesthetic incident reporting scheme in Leicester has been running for 11 years and 1000 incidents have now been reported. The scheme has successfully highlighted weaknesses where a procedural change has been able to prevent repetition. It has provided advance notification of problems which could be overcome by publicity and has been a source of educational cases. The experience of this scheme supports the use of a definition which does not include blame and allows the possibility of anonymous reporting. The scheme has evolved, driven by hospital decisions on reporting risk management cases, by inclusion of the Royal College of Anaesthetists' incident categories and by progressive refinements. Summary figures are given for the different categories of incident. These show marked similarities with previous studies.
James
R Hugh
RH
Anaesthetic Department, Leicester Royal Infirmary, Leicester LE1 5WW, UK. hugh.james@uhl-tr.nhs.uk
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000009:adverse effects*; D000761:Anesthesia Department, Hospital / Q000458:organization & administration; D000776:Anesthesiology / Q000295:instrumentation; D002648:Child; D002675:Child, Preschool; D004739:England; D004868:Equipment Failure / Q000706:statistics & numerical data; D004869:Equipment Safety; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D012307:Risk Factors; D012308:Risk Management / Q000458:organization & administration*