A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital

Introduction: A solid patient safety culture lies at the core of an effective event reporting system in a health care setting requiring a professional commitment for event reporting identification. Therefore, health care settings should provide strategies in which continuous health care education comes up as a good alternative. Traditional lectures are usually more convenient in terms of costs, and they allow us to disseminate data, information, and knowledge through a large number of people in the same room. Taking in consideration the tight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to incident reporting system and patient safety culture. Objective: The study aim was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and on the number of health care incident reports for better patient safety culture. Participants and Methods: An open-label, nonrandomized trial was conducted in ninety-nine health care professionals who were assessed in terms of their competencies (knowledge, skills, and attitudes) related to the health incident reporting system, before and after education intervention (traditional lectures given over 3 months). Results: All dimensions of professional competencies were improved after traditional lectures ( P < .05, 95% confidence interval). Conclusions: traditional lectures are helpful strategy for the improvement of the competencies for health care incident reporting system and patient safety.

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Medical incident reporting system for learning patient safety culture

The Proceedings of the Annual Convention of the Japanese Psychological Association ◽

10.4992/pacjpa.74.0_2pm008 ◽

2010 ◽

Vol 74 (0) ◽

pp. 2PM008-2PM008

Author(s):

Etsuko NAKAGAMI ◽

Keunsik PARK

Keyword(s):

Patient Safety ◽

Safety Culture ◽

Reporting System ◽

Patient Safety Culture ◽

Incident Reporting ◽

Incident Reporting System

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Canadian Anesthesia Incident Reporting System (CAIRS): The Canadian Anesthesiologists’ Society’s National Patient Safety Initiative

Canadian Journal of Anesthesia/Journal canadien d anesthésie ◽

10.1007/s12630-018-1141-z ◽

2018 ◽

Vol 65 (7) ◽

pp. 749-756 ◽

Cited By ~ 7

Author(s):

W. Scott Beattie ◽

Martin D. Culwick ◽

Hilary P. Grocott

Keyword(s):

Patient Safety ◽

Reporting System ◽

Incident Reporting ◽

Incident Reporting System ◽

National Patient ◽

Canadian Anesthesia ◽

Safety Initiative

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A Cross-sectional Overview of the First 4,000 Incidents Reported to webAIRS, a De-identified Web-based Anaesthesia Incident Reporting System in Australia and New Zealand

Anaesthesia and Intensive Care ◽

10.1177/0310057x1704500105 ◽

2017 ◽

Vol 45 (1) ◽

pp. 28-35 ◽

Cited By ~ 14

Author(s):

N. M. Gibbs ◽

M. Culwick ◽

A. F. Merry

Keyword(s):

New Zealand ◽

Reporting System ◽

Health Resources ◽

Incident Reporting ◽

Cross Sectional ◽

Web Based ◽

Incident Reporting System ◽

Wide Range ◽

American Society ◽

American Society Of Anesthesiologists

webAIRS is a web-based de-identified anaesthesia incident reporting system, which was introduced in Australia and New Zealand in September 2009. By July 2016, 4,000 incident reports had been received. The incidents covered a wide range of patient age (<28 days to >90 years), American Society of Anesthesiologists physical status, and body mass index (<18.5 to >50 kg/m2). They occurred across a wide range of anaesthesia techniques and grade of anaesthesia provider, and over a wide range of anaesthetising locations and times of day. In a high proportion the outcome was not benign; about 26% of incidents were associated with patient harm and a further 4% with death. Incidents appeared to be an ever-present risk in anaesthetic practice, with extrapolated estimates exceeding 200 per week across Australia and New Zealand. Independent of outcomes, many anaesthesia incidents were associated with increased use of health resources. The four most common main categories of incident were Respiratory/Airway, Medication, Cardiovascular, and Medical Device/Equipment. Over 50% of incidents were considered preventable. The narratives accompanying each incident provide a rich source of information, which will be analysed in subsequent reports on particular incident types. The summary data in this initial overview are a sober reminder of the prevalence and unpredictability of anaesthesia incidents, and their potential morbidity and mortality. The data justify current efforts to better prevent and manage anaesthesia incidents in Australia and New Zealand, and identify areas in which increased resources or additional initiatives may be required.

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Iatrogenic uvular injury related to airway instrumentation: A report of 13 cases from the webAIRS database and a review of uvular necrosis following inadvertent uvular injury

Anaesthesia and Intensive Care ◽

10.1177/0310057x20982623 ◽

2021 ◽

pp. 0310057X2098262

Author(s):

Matthew R Bright ◽

Sandra I Concha Blamey ◽

Linda A Beckmann ◽

Martin D Culwick

Keyword(s):

Sore Throat ◽

Reporting System ◽

Management Strategies ◽

Incident Reporting ◽

Supportive Treatment ◽

Mechanical Compression ◽

Web Based ◽

Incident Reporting System ◽

Postoperative Findings ◽

Specific Management

Published reports of uvular necrosis are uncommon and it is possibly an under-reported complication of oropharyngeal manipulation. Uvular necrosis is thought to develop due to ischaemia secondary to mechanical compression of the uvula from oropharyngeal devices. Patients typically present with symptoms of a sore throat within 48 hours postoperatively. It is unclear whether there are any preventable factors, or any specific management strategies that might reduce this complication. Treatment is most commonly conservative management, including observation and simple analgesia. We present 13 cases of uvular injury that were reported to a web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand. While the postoperative findings varied, sore throat was the most frequent symptom. Most of the cases resolved spontaneously; the remainder with supportive treatment only. The findings suggest that patients who sustain a uvular injury can be reassured, but they should be advised to seek review early if sore throat persists or any difficulty with breathing develops.

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