Improving Safety Through Incident Reporting

Abstract

Incident report systems capture structured data and the nuanced details of clinical care in a narrative format. Incident reports are used to identify and aggregate cases in which a serious adverse event (or near miss) occurs. Reporting systems can function within a department of anesthesiology, within a healthcare facility, or on a regional or national level. Technology has made it easier to capture incidents through the use of intuitive online reporting tools. Incidents are used to generate teaching cases for educational presentations and simulation that emphasize elements of safe and effective anesthesia care. Trends seen in incident reports can identify emerging risks to patient safety, a common occurrence with rapidly advancing surgical equipment and procedures. Aggregation of incident reports into regional and national systems will identify rare risks of anesthesia care that can be prevented through redesign of monitors and devices, changes in thinking, and heightened provider awareness.