INCIDENT REPORTING IN ACUTE PAIN MANAGEMENT

Incident reporting is an effective tool for continuous quality improve ment in clinical practice. A prospective study on voluntary incident r eporting in pain management was conducted at a major teaching hospital in Hong Kong. Over a 12-month period, 53 incidents were reported in 1 275 patients who received pain relief treatments which were supervised by the acute pain service. The majority of the incidents were first d etected by the pain team. The most common incidents involved delivery circuits, delivery pump and drug administration. A large proportion (8 1.4%) of the incidents were thought to be preventable. Human factors w ere involved in 41.9% of the patients reported, most commonly associat ed with unfamiliar technique/inexperience, inattention and inadequate communication Four Patients developed major morbidity of which two wer e attributed to inadequate analgesia, while three others had major phy siological changes without morbidity. Strategies have been formulated to prevent further occurrence of these incidents. We propose that inci dent reporting is a potentially useful tool in identifying and prevent ing adverse events in postoperative pain management.