Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?
Background—Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. Objectives—To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. Methods—As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. Results—During
Related Questions
- What was the sequence of events in the Water Bureau’s response to the discovery of potential contamination in the water system?
- Why is private property and the protection of property rights so critical to the success of the market system?
- Can I play System Link between both Xbox® and Xbox 360™ consoles?
