Importance of critical incident reporting

1. CRITICAL INCIDENT REPORTING
IN ANAESTHESIA: DRUG ERRORS
DR. UBA
Registrar, Department of
Anaesthesiology UBTH

2. Outline
• Introduction
• Causes of critical incidents
• Components of incident reporting system
• Analysis of reported incidents
• Components of incident analysis
• Barriers and enablers to successful incident reporting
• Drug errors
• Classification of drug errors
• Risk factors for drug errors
• Consequences of drug errors
• Prevention of drug errors
• Conclusion
• References
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3. Introduction
• A critical incident in anaesthesia is defined as any
untoward and preventable mishap associated
with the administration of general or regional
anaesthesia, and which leads to, or could have
led to an undesirable patient outcome.
• Near miss: is an event which has the potential to
lead to the substantial negative outcome if left to
progress
• The review of critical incidents occurring during
anaesthesia as well as factors contributing to
these incidents aims to improve patient safety
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4. LUTH, 2017
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5. Causes Of Critical Incidents
• Contributory factors are attributable to the
patient, surgery or anaesthesia
• Anaesthesia-related critical incidents may be
due to human errors, equipment errors, or
pharmacological factors.
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6. Causes of critical incidents- Human
Errors
• The contribution of human decisions and actions to an incident can
be due to active failures and/or latent failures
• Active failures are unsafe acts or omissions performed by front-end
workers (anaesthetists, surgeons, nurses), and these include slips
(wrong label, wrong syringe), cognitive failure (memory lapses,
ignorance, misreading a situation), or violations (deviations from
safe practices, procedures, or standards)
• Latent failures refer to decisions taken by senior management or
clinicians, which create the conditions in an organization for unsafe
acts to occur e.g. inadequate or inappropriate staffing, heavy
workload, poor supervision, stressful environment, poor
communication, poor maintenance of equipment, and conflict of
priorities (finance vs. clinical need)
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7. Incident Reporting Systems
• The main reason for reporting incidents to
improve patient safety is the belief that safety
can be improved by learning from incidents
and near misses, rather than pretending that
they have not happened
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8. Components
• Data input:
– systems for data input need to be independent
and non-punitive to enhance learning culture
• The data:
– It is vital that the staff are given opportunity to
narrate their own version of events
– This would reflect true nature of the incident,
better chronology of events, and give better feel
for the multitude of factors that link in the
evolution of an incident
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9. • Analysis:
– Requires experts from the speciality, and human
performance (or safety), to work together to interrogate
data and generate meaningful learning outcomes
– Standardized methodology should be adopted at this stage
• Feedback:
– Sharing of ideas by all parties involved
– abandon defensiveness, blame and recriminations
– Goal is to learn from mistakes, and to ensure that the
systems are improved for better patient safety in the
future
– Multiple sources, from the high-level managerial staff to
the front-end clinical staff
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10. Analyses of Reported Incidents
• Comprehensive analysis of incidents must pay
attention to psychological and human factors in
the nature, mechanisms, and causes of the error
• In this regard, the national reporting systems
have to work alongside the local risk
management structures for comprehensive
analyses and cross-learning from the incidents
• A standardized framework should be used at all
levels for analysis of the incidents
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11. • A high-level analysis of the number and kinds of incidents
can be performed at the national level, and disseminated
widely.
• Highlighting the areas for improvement (e.g. medication
errors, retained throat packs), and for further focus by
national organizations
• Follow up by further actions such as raising awareness,
research, audits, training initiatives, curriculum, and
specific guidelines
• Local safety initiatives of investigating and analysing
incidents are extremely important to get into the root
cause of the incidents and how these can be prevented in
the future
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12. Components of Incident Analysis
• Identifying the most obvious active failure(s)
– Also known as care management problems (CMP).
These include delayed diagnosis, inadequate
handover, failure to monitor, lack of preoperative
check, protocol violation, incorrect treatment, not
seeking help, inadequate supervision, etc.
• Framing the problem
– Accurate assessment of chronology and the
details of the events leading on to the incident is
important in framing the problem.
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13. • Defining the problem (what, how, and why)
– case notes studies and interviews of the key staff members
– first determine exactly what happened in terms of CMPs and
chronology of the events.
– next, establish, without being punitive, how it happened:
important acts or omissions made by staff, and with hindsight
the important chain of events which set up the conditions for
the incident to occur, reasons behind the acts or omissions.
– define why: For each CMP, explore contributory factors. E.g. lack
of knowledge or training at individual level, unavailability of
protocols at task level, poor communication at team level,
inadequate staffing at organizational level, overstretched staff
rotas, or faulty/incomprehensible guidelines.
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14. • A separate analysis should be carried out for
each CMP using a standardized framework.
• The final analysis will report summary of
chronology, CMPs, and their contributory
causes, and give recommendations for further
actions for each contributory factor
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15. Barriers and Enablers to Incident
Reporting
• Despite the known and well-advertised strengths of the
incident reporting systems, under-reporting, in
particular by doctors, remains a significant problem
• One of the reasons could be unfamiliarity with the
process
• Other factors which have been identified are cultural
issues such as fear of punitive action, legal
ramifications, and discrimination at the workplace.
• Poor reporting practices by doctors may also reflect
prevailing deeply entrenched belief in medicine that
only bad doctors make mistakes
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16. Factors Contributing to Successful Error
Reporting
• Flexible and learning culture
• Accept human fallibility
• Training on safety issues
• Annual appraisal
• Establish ground rules: acceptable and
unacceptable behaviour
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17. Factors Contributing to Successful Error
Reporting
• Support / trust / leadership
• Feedback
• Implementing necessary changes
• Consistency
• Clear instructions
• Anonymity
• Confidentiality
• Voluntary
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Barriers to Successful Reporting
• Fear of individual / organisational
repercussion
• Defining reportable errors too narrowly
• Workload involved in reporting
• Culture of fear of getting a bad reputation
• No changes with previous reporting
• Uncertainty: differing opinions between right
and wrong

19. Drug Errors
• Definition: error in the prescription, dispensing, or
administration of a medication with the result that the patient
fails to receive the correct drug or the indicated proper drug
dosage
• The drug errors could be inappropriate dosing, wrong
sequence of administration, administration of a drug different
from what was intended, or administration of a drug which
the patient is allergic to.
• Drug errors could occur as a result of syringe swaps or
ampoule swaps
• Commoner during general anaesthesia than during regional
anaesthesia due to the fact that fewer drugs are used for
regional than for general anaesthesia
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20. Webster’s Classification of Drug Errors
Omission: drug not given
Repetition: extra dose of an intended drug
Substitution: incorrect drug instead of the
desired drug; a swap
Insertion: a drug that was not intended to
be given at a particular time or at any time
Incorrect dose: wrong dose of an intended drug
Incorrect route: wrong route of an intended drug
Other: usually a more complex event not fitting the
categories above
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21. Risk Factors for Drug Errors
• Inadequate total experience
• Inadequate familiarity with equipment or device
• Poor communication with team
• Haste
• Inattention/carelessness
• Fatigue
• Failure to perform normal check
• Lack of supervision
• Inadequate familiarity with surgery
• Inadequate familiarity with anaesthetic technique
• Distraction
• Poor labelling of drugs
• Apprehension
• Demanding or difficult case
• Emergency case
• Boredom
• Insufficient preparation
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22. Consequences of Drug Errors
• Death
• Permanent disability
• Lack of confidence in healthcare organizations
• Litigation
• Guilt
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23. Prevention of Medication Errors
• The label on any drug ampoule or syringe should be read
carefully before the drug is drawn up or injected.
• Legibility and contents of labels on ampoules and syringes
should be optimized according to agreed standards with
respect to font, size, colour and information.
• Syringes should always be labelled.
• Double checking of ampoules, syringes and equipment before
starting the procedure
• Formal organisation of drug drawers and work space should
be used with attention to tidiness, position of ampoules and
syringes, separation of look-alike drugs and removal of
dangerous drugs from the operation room.
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24. Prevention Cont’d
• Labels should be checked specifically with the help of a second
person or a device like bar code reader before administration.
• Error during administration should be reported and reviewed.
• Management of inventory should focus on minimising the risk of
drug error.
• Look-alike packaging and presentation of the drug should be
avoided where possible.
• Drug should be presented in prefilled syringes rather than
ampoules.
• Drug should be drawn up and labelled by the anaesthesia provider
himself/herself.
• Colour coding by class of drugs should be according to an agreed
national or international standard.
• Coding of syringe according to position or size should be done.
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25. Conclusion
• Despite the best efforts, the increased use of
technology and high standards of both
invasive and non-invasive monitoring in
anaesthesia and critical care, medication
errors continue to occur even at the best
centres worldwide.
• Simple vigilance, standardised protocol, and
‘think before act’ are the key factors to avoid
occurrence of medication errors.
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26. References
• Critical incidents and near misses during anesthesia: A prospective audit
Journal of Clinical Sciences
Pamela Onorame Agbamu1, Ifeyinwa Dorothy Menkiti1, Esohe Ivie
Ohuoba1, Ibironke Desalu2
• Critical incident reporting and learning R. P. Mahajan BJA: British Journal
of Anaesthesia, Volume 105, Issue 1, July 2010, Pages 69-
75, https://doi.org/10.1093/bja/aeq133
• Drug Errors and Protocol for Prevention among Anaesthetists in
Nigeria Anesthesiology Research and Practice, vol. 2017, Article ID
2045382, 4 pages, 2017 https://doi.org/10.1155/2017/2045382 U. U.
Johnson, L. N. Ebirim
• Medication error in anaesthesia and critical care: A cause for concern
Indian J Anaesth. 2010 May-Jun; 54(3): 187–192. Dilip Kothari, Suman
Gupta, Chetan Sharma, and Saroj Kothari
• Medication errors in anaesthetic practice: a report of two cases and
review of the literature Afr Health Sci. 2013 Sep; 13(3): 845–849. E Ogboli-
Nwasor https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824420/
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27. THANK YOU
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