Enhancing patient safety by integrating ethical dimensions to Critical Incident Reporting Systems

Background Critical Incident Reporting Systems (CIRS) provide a well-proven method to identify clinical risks in hospitals. All professions can report critical incidents anonymously, low-threshold, and without sanctions. Reported cases are processed to preventive measures that improve patient and staff safety. Clinical ethics consultations offer support for ethical conflicts but are dependent on the interaction with staff and management to be effective. The aim of this study was to investigate the rationale of integrating an ethical focus into CIRS. Methods A six-step approach combined the analysis of CIRS databases, potential cases, literature on clinical and organizational ethics, cases from ethics consultations, and experts’ experience to construct a framework for CIRS cases with ethical relevance and map the categories with principles of biomedical ethics. Results Four main categories of critical incidents with ethical relevance were derived: (1) patient-related communication; (2) consent, autonomy, and patient interest; (3) conflicting economic and medical interests; (4) staff communication and corporate culture. Each category was refined with different subcategories and mapped with case examples and exemplary related ethical principles to demonstrate ethical relevance. Conclusion The developed framework for CIRS cases with its ethical dimensions demonstrates the relevance of integrating ethics into the concept of risk-, quality-, and organizational management. It may also support clinical ethics consultations’ presence and effectiveness. The proposed enhancement could contribute to hospitals’ ethical infrastructure and may increase ethical behavior, patient safety, and employee satisfaction.

Erkenntnisse aus 10 Jahren CIRS‑AINS

Zusammenfassung Hintergrund „Critical-incident-reporting“-Systeme (CIRS) dienen dazu, Organisationen und Individuen für bislang unbekannte und sicherheitsrelevante Ereignisse zu sensibilisieren und dadurch Veränderungen herbeiführen zu können. In den letzten Jahren häufen sich allerdings kritische Stimmen, die Einsatz und Nutzen von CIRS in der Medizin hinterfragen, u. a. aufgrund unklarer bzw. zu allgemeiner inhaltlicher Kriterien für die Aufnahme einer Meldung in ein System. Ziel der Arbeit ist die Auswertung und Analyse aller Fälle aus CIRSmedical Anästhesiologie (CIRS-AINS) als Grundlage weiterer, differenzierter Betrachtungen. Methode In einer retrospektiven Datenbankanalyse wurden alle Fälle aus CIRS-AINS (April 2010–Juni 2019) inhaltlich analysiert. Ergebnisse Die gemeldeten 6013 Fälle setzen sich aus 3492 „incidents“ (58,1 %), 1734 „near-misses“ (28,8 %) und 787 sonstigen Meldungen (13,1 %) zusammen. Unter Letztere fielen 21 Konfliktmeldungen (0,4 %), 102 Beschwerden (1,7 %), 89 Überlastungsanzeigen (1,5 %) sowie 575 sonstige Meldungen, die keine CIRS-Fälle darstellen (9,6 %). Seit 2015 zeigt sich eine stetige Zunahme der sonstigen Meldungen um das 2,8-Fache von 7,4 % auf 20,8 %. In 20,1 % der Meldungen wurde Technik, in 27,7 % Medizinprodukte erwähnt. Medikamente waren in 10,7 % der Meldungen Gegenstand der Zwischenfälle. Aus dem perioperativen Umfeld wurden 47,8 % der stationären Zwischenfälle berichtet, 24,6 % aus den Bereichen Intensivstation/Aufwachraum. Das CIRS-Team des BDA analysierte und kommentierte 36,1 % der Fälle . Schlussfolgerung Die Analyse liefert Erkenntnisse für die Gestaltung zukünftiger Melderichtlinien und Anwenderschulungen. Insbesondere der Häufung „sonstiger“ Meldungen, welche nicht den Kriterien einer CIRS-Meldung entsprechen, sollte künftig Rechnung getragen werden.

Improving critical incident reporting in primary care through education and involvement

BackgroundCritical incident reporting systems (CIRS) can be an important tool for the identification of organisational safety needs and thus to improve patient safety. In German primary care, CIRS use is obligatory but remains rare. Studies on CIRS implementation in primary care are lacking, but those from secondary care recommend involving management personnel.ObjectiveThis project aimed to increase CIRS use in 69 practices belonging to a local practice network.MethodsThe intervention consisted of the provision of a web-based CIRS, accompanying measures to train practice teams in error management and CIRS, and the involvement of the network’s management. Three measurements were used: (1) number of incident reports and user access rates to the web-based CIRS were recorded, (2) staff were given a questionnaire addressing incident reporting, error management and safety climate and (3) qualitative reflection conferences were held with network management.ResultsOver 20 months, 17 critical incidents were reported to the web-based CIRS. The number of staff intending to report the next incident online decreased from 42% to 20% of participants. In contrast, the number of practices using an offline CIRS (eg, incident book) increased from 23% to 49% of practices. Practices also began proactively approaching network management for help with incidents. After project completion, participants scored higher in the patient safety climate factor ‘perception of causes of errors’. For many practices, the project provided the first contact with structured error management.ConclusionSpecific measures to improve the use of CIRS in primary care should focus on network management and practice owners. Practices need basic training on safety culture and error management. Continuing, practices should implement an offline CIRS, before they can profit from the exchange of reports via web-based CIRS. It is crucial that practices receive feedback on incidents, and trained network management personnel can provide such support.