Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department

作者：Guffey Patrick^*; Szolnoki Judit; Caldwell James; Polaner David

来源：Paediatric Anaesthesia, 2011, 21(7): 810-814.

DOI：10.1111/j.1460-9592.2011.03574.x

• near miss
• incident report
• mortality
• adverse events

P>Background:
Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented.
Methods:
An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system.
Results:
A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago.
Conclusion:
An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.

• 出版日期2011-7