Rk. Webb et al., THE AUSTRALIAN INCIDENT MONITORING STUDY - AN ANALYSIS OF 2000 INCIDENT REPORTS, Anaesthesia and intensive care, 21(5), 1993, pp. 520-528
Citations number
39
Categorie Soggetti
Anesthesiology,"Emergency Medicine & Critical Care
The Australian Patient Safety Foundation was formed in 1987, it was de
cided to set up and co-ordinate the Australian Incident Monitoring Stu
dy as a function of this Foundation, 90 hospitals and practices joined
the study. Participating anaesthetists were invited to report, on an
anonymous and voluntary basis, any unintended incident which reduced,
or could have reduced, the safety margin for a patient. Any incident c
ould be reported, not only those which were deemed ''preventable'' or
were thought to involve human error The Mark I AIMS form was developed
which incorporated features and concepts from several other studies.
All the incidents in this symposium were reported using this form, whi
ch contains general instructions to the reporter, key words and space
for a narrative of the incident, structured sections for what happened
(with subsections for circuitry incidents, circuitry involved, equipm
ent involved, pharmacological incidents and airway incidents), why it
happened (with subsections for factors contributing to the incident, f
actors minimising the incident and suggested corrective strategies), t
he type of anaesthesia and procedure, monitors in use, when and where
the incident happened, the experience of the personnel involved, patie
nt age and a classification of patient outcome. Enrolment, reporting a
nd data-handling procedures are described. Data on patient outcome are
presented; this is correlated with the stages at which the incident o
ccurred and with the ASA status of the patients. The locations at whic
h the incidents occurred and the types of procedures, the sets of inci
dents analysed in detail and a breakdown of the incidents due to drugs
are also presented. The pattern and relative frequencies of the vario
us categories of incidents are similar to those in ''closed-claims'' s
tudies, suggesting that AIMS should provide information of relevance t
o those wishing to develop strategies to reduce the incidence and/or i
mpact of incidents and accidents.