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Anesthesiology:
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Learning from Incidents and Near-misses Reports

Haller, Guy M.D.*; Myles, Paul S. M.B., B.S., M.P.H., M.D., F.C.A.R.C.S.I., F.A.N.Z.C.A.

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To the Editor:—

We strongly support reporting systems and therefore read with interest the Editorial View by Auroy et al.1 However, before these methods become a standard audit or educational tool, some of their limitations must be considered further.
Clinicians can often select the type of adverse incident or outcome they will record. These tend to be those that are more severe, or those in accordance with individual perspectives of safety.2,3 For example, prolonged paralysis after a regional block is more likely to be reported than transitory paresthesia. Temporary complications are often ignored, despite their potential educational value. Sometimes, reporters select those incidents most likely to carry a message to the organization’s management.4 Incidents over inappropriate waiting times for patients or surgeons are not exceptional in anesthetic incident–reporting systems. Such selection and reporting biases may seriously distort perception of safety problems in anesthesia.
When reporting systems focus on near misses (prevented or mitigated adverse events), another difficulty arises, one familiar to aviation safety experts: information overload.4 A progressively larger amount of data is collected and stored to be further analyzed. It can become increasingly difficult and costly to classify and retrieve meaningful events in such an extensive system analysis.5 Gradually limited by resources and complexity, experts may end up fixing near misses instead of addressing system errors concealed behind the data overload. This may jeopardize the didactic value of such events.
Finally, anesthetic and medical practices in general are largely controlled by a professional body of knowledge.6 Organizational guidelines and standards are much less the norm than, for example, in chemical or nuclear industries.7 Variability in local practices, professional culture, and political context seriously challenge the generalizability of organizational analysis.
To address these problems, suggested approaches could include the use of international standardized definitions of incidents and the development of guided reporting through generic adverse event indicators. The specificities of the healthcare organization analyzed could also be more systematically described and addressed.
If limitations such as these are not well understood and properly addressed, case reports and root cause analyses of adverse incidents and near misses are likely to remain largely narrative and of limited educational value within the broader anesthetic community.
Guy Haller, M.D.,*
Paul S. Myles, M.B., B.S., M.P.H., M.D., F.C.A.R.C.S.I., F.A.N.Z.C.A.
* Alfred Hospital, Melbourne, Australia. guy.haller@med.monash.edu.au
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References

1. Auroy Y, Benhamou D, Amalberti R: Risk assessment and control require analysis of both outcomes and process of care. Anesthesiology 2004; 101:815–7

2. Stanhope N, Crowley-Murphy M, Vincent C, O’Connor AM, Taylor-Adams SE: An evaluation of adverse incident reporting. J Eval Clin Pract 1999; 5:5–12

3. Vincent C, Stanhope N, Crowley-Murphy M: Reasons for not reporting adverse incidents: An empirical study. J Eval Clin Pract 1999; 5:13–21

4. Amalberti R: Revisiting safety paradigms to meet the safety challenges of ultra complex and safety systems, System Safety: Challenges and Pitfalls of Intervention, 1st edition. Edited by Wilpert B, Fahlbruch B. Amsterdam, Pergamon Publishers, 2002, pp 265–76

5. Johnson CW: How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events. Qual Saf Health Care 2003; 12 (suppl 2):ii64–7

6. Shortell SM, Kaluzny AD: Health Care Management: Organization, Design, and Behavior, 4th edition. Albany, New York, Delmar Publishers, 2000, pp 12–3

7. Glouberman S, Mintzberg H: Managing the care of health and the cure of disease: II. Integration. Health Care Manage Rev 2001; 26:70–84

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