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Defining and reporting critical incidents in anaesthesia
- Jeffrey Perring (8 August 2006)
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Critical incident under-reporting
- Karen MA Wouters (6 July 2006)
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Jeffrey Perring
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Editor - I read with interest the paper by Smith and colleagues concerning the reporting of adverse events in anaesthetic practice 1. These researchers have highlighted a situation that is familiar to many of us; that despite a definition of critical incidents by the Royal College of Anaesthetists 2 there is still no agreement as to which incidents should be reported. Amongst those incidents that are reported there is no agreement as to whether they should remain within the anaesthetic department as a learning opportunity or be sent to the Trust’s local incident reporting scheme and thereby to the National Patient Safety Agency’s National Reporting and Learning System 3. It is clear that anaesthesia is different from other areas of patient care and that an important element of an anaesthetist’s role is to manage the clinical events which will inevitably occur. A large proportion of these events will carry with them a potential for harm if not managed appropriately. This potential for harm is central to the definition of critical incidents. The question then arises as to whether all of these clinical events should be reported as critical incidents or if a subsection of them can be defined separately as critical incidents and reported as such? The authors of this paper have put forward a possible explanation as to why so many events are not reported, that an experienced anaesthetist develops a ‘definitional power’ 1. This power enables the anaesthetist to decide whether an event should be regarded as routine or critical and therefore whether it should be reported. However, this will inevitably lead to variation in incident reporting based on individual perception and experience and cannot be regarded as an acceptable approach to reporting within a specialised and high risk organisation, an NHS Trust. I would suggest that there needs to be a more prescribed approach to the definition of critical incidents. The definition of critical incidents should include model examples that are well recognised by all anaesthetists. This type of approach is best developed at a national level with input from representatives of all those involved in patient safety not just clinicians. It is unacceptable for the situation described by Smith and colleagues to continue. J. Perring. Sheffield, UK. jeffperring@mac.com. 1. Smith AF, Goodwin D, Mort M, Pope C. Adverse events in anaesthetic practice: a qualitative study of definition, discussion and reporting. Br J Anaesth 2006; 96: 715-21 2. www.rcoa.ac.uk (Accessed July 21, 2006) 3. www.npsa.nhs.uk (Accessed July 21, 2006) Conflict of Interest:None declared |
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Karen MA Wouters
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Editor- I read with interest the
article by Smith and colleagues on adverse events in anaesthetic practice. I
have recently completed an audit in our anaesthetic department to ascertain the
reason why critical incidents are under-reported. My audit relied on both
consultants and registrars completing an anonymous questionnaire, the results of
which are summarised in the table below. I was pleasantly surprised to see that
we are overcoming the era of “blame culture” and that triviality was the most
common reason for under-reporting. I, as do some of my colleagues anaesthetists,
agree that the definition of “criticality” is ambiguous. As a result most of us
would not regard situations such as laryngospasm and circuit disconnection as a
“critical” incident. Anaesthesia as a speciality is fraught with life
threatening situations that are not necessarily unexpected. If these
situations are treated promptly and appropriately without consequence, are they
truly “critical” incidents? However, I feel that unusual events or situations
where a lesson can be learnt should be reported as they are an essential
learning tool that without a doubt contributes to patient safety. Reasons for not filling in Critical incident (CI ) forms:
Conflict of Interest:None declared |
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