title: Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data.
abstract: OBJECTIVE
  Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results.
  
  
  METHODS
  In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed.
  
  
  RESULTS
  Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases).
  
  
  CONCLUSIONS
  Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.
authors.affiliation: Department of Neurosurgery, Fondazione Istituto Neurologico "Carlo Besta," Milano, Italy. pferroli@istituto-besta.it
authors.forename: Paolo
authors.initials: P
authors.lastname: Ferroli
authors.forename: Dario
authors.initials: D
authors.lastname: Caldiroli
authors.forename: Francesco
authors.initials: F
authors.lastname: Acerbi
authors.forename: Maurizio
authors.initials: M
authors.lastname: Scholtze
authors.forename: Alfonso
authors.initials: A
authors.lastname: Piro
authors.forename: Marco
authors.initials: M
authors.lastname: Schiariti
authors.forename: Eleonora F
authors.initials: EF
authors.lastname: Orena
authors.forename: Melina
authors.initials: M
authors.lastname: Castiglione
authors.forename: Morgan
authors.initials: M
authors.lastname: Broggi
authors.forename: Alessandro
authors.initials: A
authors.lastname: Perin
authors.forename: Francesco
authors.initials: F
authors.lastname: DiMeco
mesh_terms: D001359:Aviation / Q000592:standards*; D003627:Data Interpretation, Statistical; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D017146:Models, Organizational; D019635:Neurosurgical Procedures / Q000592:standards*; D009873:Operating Rooms; D061214:Patient Safety; D011183:Postoperative Complications / Q000517:prevention & control; D017751:Safety Management / Q000379:methods; D013647:Task Performance and Analysis