Another example from everyday hospital life: time and again, ventilation tubes slipped out of intubated infants in a children’s hospital. After reports of these incidents increased, a physician did some research and found that a new, less expensive patch had been purchased. Unfortunately, it was sticking poorly, especially to intubated infants. Thanks to a reporting system, this safety gap was quickly closed.
This Critical Incident Reporting System (CIRS) is a reporting system for reporting critical events (“critical incident”) in healthcare facilities. In 2007, the Patient Safety Action Alliance issued recommendations for the general implementation of CIRS. The systems were originally developed in engineering for airline pilots, for example. For clinicians and specialists, there has been “CIRSmedical” since 2005, organized by the Medical Center for Quality in Medicine.
In November 2007, the Institute for Health and Medical Law (IGMR) at the University of Bremen and the AOK-Bundesverband presented the results of a project on the use of CIRS together with twelve children’s hospitals at a conference. Around 1,300 reports were collected from the wards during the project period and analyzed and evaluated by IGMR. The results: “Critical events” during treatment with medication formed the main focus at 35 percent.
Deficiencies in the clinic
The clinic personnel – of it 73 per cent from the care range and 27 per cent physicians – reported in the range medicament therapy above all problems with the preparation of medicaments (61 per cent), with the prescription were it 34 per cent as well as five per cent with the distribution by the pharmacy.
The second most frequent risk focus (24 percent) was deviation from medical or nursing standards, followed by inadequate documentation (15 percent) and organization (nine percent). Typical risk situations in day-to-day clinical practice were medication mix-ups, interrogation, misreading/ miscounting, and lack of labeling for medications.
It has been shown that the reporting system used can help to uncover critical events, especially in typical routine procedures and in standards that have been practiced for a long time. It is less suitable for tracking down complex error chains or uncovering organizational deficiencies. Despite this limitation, CIRS is an effective tool for improving patient safety because it can prevent the transition from error to harm.
