title: The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events.
abstract: BACKGROUND
  The reduction of perioperative harm is a major priority of in-hospital health care and the reporting of incidents and their causes is an important source of information to improve perioperative patient safety. We explored the number, nature and causes of voluntarily reported perioperative incidents in order to highlight the areas where further efforts are required to improve patient safety.
  
  
  METHODS
  Data from the Hospital Incident Management System (HIMS), entered in the period from July 2009 to July 2012, were analyzed in a Dutch university hospital. Employees in the perioperatve field filled out a semi-structured digital form of the reporting system. The risk classification of the reported adverse events and 'near misses' was based on the estimated patient consequences and the risk of recurrence, according to national guidelines. Predefined reported incident causes were categorized as human, organizational, technical and patient related.
  
  
  RESULTS
  In total, 2,563 incidents (1,300 adverse events and 1,263 'near-miss' events) were reported during 67,360 operations. Reporters were anesthesia, operating room and recovery nurses (37%), ward nurses (31%), physicians (17%), administrative personnel (5%), others (6%) and unmentioned (3%). A total of 414 (16%) adverse events had patient consequences (which affected 0,6% of all surgery patients), estimated as catastrophic in 2, very serious in 34, serious in 105, and marginally serious in 273 cases. Shortcomings in communication was the most frequent reported type of incidents. Non-compliance with Standard Operating Procedures (SOPs: instructions, regulations, protocols and guidelines) was reported with 877 (34%) of incident reports. In total, 1,194 (27%) voluntarily reported causes were SOP-related, mainly human-based (79%) and partially organization-based (21%). SOP-related incidents were not associated with more patient consequences than other voluntarily reported incidents. Furthermore 'mistake or forgotten' (15%) and 'communication problems' (11%) were frequently reported causes of incidents.
  
  
  CONCLUSIONS
  The analysis of voluntarily reported perioperative incidents identified an association between perioperative patient safety problems and human failure, such as SOP non-compliance, mistakes, forgetting, and shortcomings in communication. The data suggest that professionals themselves indicate that SOP compliance in combination with other human failures provide room for improvement.
authors: Department of Operating Theatres, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Internal postal code 738, 6525 GA Nijmegen, The Netherlands.
authors: Anita J
authors: AJ
authors: Heideveld-Chevalking
authors: Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
authors: Hiske
authors: H
authors: Calsbeek
authors: Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors: Johan
authors: J
authors: Damen
authors: Department of Operating Theatres, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Internal postal code 738, 6525 GA Nijmegen, The Netherlands.
authors: Hein
authors: H
authors: Gooszen
authors: Department of Operating Theatres, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Internal postal code 738, 6525 GA Nijmegen, The Netherlands ; Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors: André P
authors: AP
authors: Wolff
keywords: Guideline adherence; Hospital incident reporting; Patient safety; Perioperative care; Quality improvement
references: BMJ. 2001 Mar 3;322(7285):517-9
references: 11230064
references: Patient Saf Surg. 2011 May 20;5:13
references: 21599915
references: BMJ Qual Saf. 2012 Mar;21(3):191-7
references: 22069112
references: BMJ. 1998 Apr 11;316(7138):1154-7
references: 9552960
references: Curr Opin Crit Care. 2010 Dec;16(6):649-53
references: 20930624
references: Qual Health Care. 2000 Dec;9(4):203-9
references: 11101704
references: Surgery. 1999 Jul;126(1):66-75
references: 10418594
references: Br J Anaesth. 2011 Aug;107(2):171-9
references: 21642277
references: Qual Saf Health Care. 2006 Dec;15 Suppl 1:i66-71
references: 17142612
references: Br J Anaesth. 2006 Jun;96(6):715-21
references: 16698867
references: Am J Surg. 2013 Aug;206(2):253-62
references: 23642651
references: BMJ. 2000 Mar 18;320(7237):759-63
references: 10720361
references: PLoS One. 2012;7(9):e44599
references: 22962619
references: BMJ. 2012 Jan 13;344:e386
references: 22246454
references: Int J Qual Health Care. 2013 Apr;25(2):141-50
references: 23335058
references: Ann Surg. 2012 Jan;255(1):44-9
references: 22123159
references: Psychol Bull. 1954 Jul;51(4):327-58
references: 13177800
references: Med Care. 2011 Oct;49(10):948-55
references: 21642876
references: Anesthesiology. 1978 Dec;49(6):399-406
references: 727541
references: Ann Surg. 2012 Dec;256(6):925-33
references: 22968074
references: Qual Saf Health Care. 2003 Oct;12(5):321-2
references: 14532356
references: Med Care. 2006 Feb;44(2):117-23
references: 16434910
references: Qual Saf Health Care. 2007 Oct;16(5):342-8
references: 17913774
references: Br J Anaesth. 2010 Jul;105(1):69-75
references: 20551028
references: BMJ. 2000 Mar 18;320(7237):768-70
references: 10720363
references: N Engl J Med. 1991 Feb 7;324(6):370-6
references: 1987460
references: J Patient Saf. 2010 Dec;6(4):247-50
references: 21500613
references: Qual Saf Health Care. 2004 Oct;13(5):330-4
references: 15465935
references: J Patient Saf. 2010 Dec;6(4):226-32
references: 21099551
references: Med J Aust. 2004 Jul 5;181(1):36-9
references: 15233611
references: Lancet. 1997 Feb 1;349(9048):309-13
references: 9024373
references: Cochrane Database Syst Rev. 2012 Aug 15;(8):CD005609
references: 22895951