Anesthesia incident reporting systems aim to identify and aggregate adverse events in anesthesia care [1, 2]. They typically consist of a brief description of the patient, the context in which the practitioner saw the patient, and the adverse event that occurred [2]. Medical professionals input this information into a database which may then be accessible by a single anesthesiology department, a healthcare facility, regional institutions, or even an entire national or international healthcare system [2]. The aspiration is that, by making incidents publicly accessible to other practitioners, an anesthesia incident reporting system can help prevent future, similar errors.
Reporting systems are not unique to medicine: they have long been in use in other industries, such as the nuclear power and airline industries [1]. Nevertheless, they have deep roots in anesthesia, with the practice of spreading learning lessons from incidents by word-of-mouth or via letter long being common among anesthesiologists [1]. In 1954, Flanagan was the first to describe the “critical incident technique;” a few years later came a report on critical incidents owing to hospital medication errors, followed by the formal introduction of reporting to the United States in 1978 [1]. The digital age has since prompted a transformation in reporting systems, as files have changed from written to digital format and information has become easier to disseminate widely [2].
Designing an effective anesthesia incident reporting system is no easy feat. Dutton recommends that systems incorporate twenty-five elements, including being “easy to find,” containing “no mandatory elements,” providing an “option for anonymous data entry,” and assuring confidentiality [2]. However, researchers have debated the value of anonymity. Anonymity eases practitioner concerns of reputational damage and, thus, discourages subsequent underreporting [1, 3]. However, it also eliminates the possibility of personal feedback, meaning that individual anesthesiologists may not receive instruction on how to avoid similar incidents unless their conduct reflects a larger, identified trend [3]. Arnal-Velasco and Barach suggest that the solution to this issue is the development of trust by practitioners, which could include introducing protective legislation to lower or rule out the risk of retaliation [4]. Notwithstanding this potential solution, this example indicates how any system would have to reconcile trade-offs, thereby rendering the design rather complex.
Still, the various benefits of reporting systems may make them worth the struggle. Because of the power of the narrative-based structure, an anesthesia incident reporting system can help develop teaching cases for educational simulations and presentations [2].
Meta-analyses of incident reports can also help identify incident trends among practitioners and thus be used to recommend changes in practice to reduce risks [2, 5]. For example, Schulz and colleagues referred to the German anesthesia incident reporting system to track the frequency with which situation awareness errors occurred [6]. Their subsequent finding that such errors occurred in 81.5% of analyzed cases, particularly on the levels of perception and comprehension, provided helpful instruction for regional improvement in anesthesia care [6]. This example demonstrates the power of reporting systems in identifying actionable areas for improvement [6]. It is important to note, however, that data alone is not intrinsically helpful; the willingness of stakeholders to turn data into action is key to unlocking the benefits of reporting databases [7].
Anesthesia incident reporting systems can be valuable tools for tracking outcomes and instructing anesthesia practitioners. To ensure that systems are maximally effective, they, like the practice of the professionals they document, should continuously be assessed and revised.
References
[1] P. J. Guffey, M. Culwick, and A. F. Merry, “Incident Reporting at the Local and National Level,” International Anesthesiology Clinics, vol. 52, no. 1, pp. 69-83, Winter 2014. [Online]. Available: https://doi.org/10.1097/AIA.0000000000000008.
[2] R. P. Dutton, “Improving Safety Through Incident Reporting,” Current Anesthesiology Reports, vol. 4, pp. 84-89, January 2014. [Online]. Available: https://doi.org/10.1007/s40140-014-0048-7.
[3] J. C. de Graaff et al., “Anesthesia-related critical incidents in the perioperative period in children; a proposal for an anesthesia-related reporting system for critical incidents in children,” Pediatric Anesthesia, vol. 25, no. 6, pp. 621-629, February 2015. [Online]. Available: https://doi.org/10.1111/pan.12623.
[4] D. Arnal-Velasco and P. Barach, “Anaesthesia and perioperative incident reporting systems: Opportunities and challenges,” Best Practice & Research Clinical Anaesthesiology, vol. 35, no. 1, pp. 93-103, May 2021. [Online]. Available: https://doi.org/10.1016/j.bpa.2020.04.013.
[5] R. Botney, “Improving Patient Safety in Anesthesia: A Success Story?,” International Journal of Radiation Oncology – Biology – Physics, vol. 71, no. 1, supp. 1, pp. S181-2186, May 2008. [Online]. Available: https://doi.org/10.1016/j.ijrobp.2007.05.095.
[6] C. M. Schulz et al., “Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system,” BMS Anesthesiology, vol. 16, no. 4, pp. 1-10, January 2016. [Online]. Available: https://doi.org/10.1186/s12871-016-0172-7.
[7] R. P. Dutton, “Making a Difference: The Anesthesia Quality Institute,” Anesthesia & Analgesia, vol. 120, no. 3, pp. 507-09, March 2015. [Online]. Available: https://doi.org/10.1213/ANE.0000000000000615.