Implementation of a critical incident reporting system in a neurosurgical department

Zentralblatt fur Neurochirurgie

Volumn 72, Issue 1, 2011, Pages 15-21

  Kantelhardt, P ^a   Muller M ^b   Giese, A ^c   Rohde, V ^c   Kantelhardt, S R ^c  

^a Working Group Medication Safety   (Germany)

^b Deutsche Lufthansa AG   (Germany)

^c UNIVERSITY OF GÖTTINGEN   (Germany)

Author keywords

critical incident; reporting system; safety gap

Indexed keywords

ARTICLE; CRITICAL INCIDENT REPORTING SYSTEM; ERROR; HEALTH CARE PLANNING; HOSPITAL DEPARTMENT; HOSPITAL PERSONNEL; HUMAN; MEDICAL DOCUMENTATION; MEDICAL SPECIALIST; MEDICATION ERROR; MULTIPLE CHOICE TEST; NEUROSURGERY; ONLINE SYSTEM; RISK ASSESSMENT; RISK FACTOR; VOLUNTARY REPORTING;

ALGORITHMS; DATA COLLECTION; DATA INTERPRETATION, STATISTICAL; FORMS AND RECORDS CONTROL; HOSPITAL DEPARTMENTS; MEDICAL ERRORS; NEUROSURGERY; PERSONNEL SELECTION; PERSONNEL, HOSPITAL; RISK FACTORS; RISK MANAGEMENT; SAFETY; TASK PERFORMANCE AND ANALYSIS;

EID: 79951914799     PISSN: 00444251     EISSN: 14389746     Source Type: Journal    
DOI: 10.1055/s-0029-1243199     Document Type: Article

References (29)

1. Bundesministerium für Gesundheit. Aktionsplan 2008/2009 zur Verbesserung der Arzneimitteltherapiesicherheit (AMTS) in Deutschland. http://www.ap-amts.de [last accessed 11/20/2009]
2. Hoppe J. D., Schrappe M., Aktionsbündnis Patientensicherheit e.V. Aus Fehlern lernen. http://www.gesundheits.de/bagp/BAGP-Dokumente/Aus-Fehlern- lernen.pdf [last accessed 11/20/2009]
3. Choy CY. Critical incident monitoring in anaesthesia. Curr Opin Anaesthesiol 2008; 21: 183-186
4. Flanagan JC. The critical incident technique. Psychol Bull 1954; 51: 327-358
5. Katz RI, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program. Anesth Analg 2000; 90: 344-350 (Pubitemid 30078013)
6. Haller U, Welti S, Haenggi D et al. From the concept of guilt to the value-free notification of errors in medicine. Risks, errors and patient safety. Gynakol Geburtshilfliche Rundsch 2005; 45: 147-160 (Pubitemid 40910971)
7. Kobberling J. The critical incident reporting system (CIRS) as a measure to improve quality in medicine. Med Klin (Munich) 2005; 100: 143-148 (Pubitemid 40521576)
8. Reissner P, Schnurrer JMM. Strategien zur Vermeidung von Risiken in der Arzneimitteltherapie. Krankenhauspharmazie 2008; 29: 343-349
9. Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Med Care 2007; 45: 997-1002
10. Grant MJ, Donaldson AE, Larsen GY. The safety culture in a children's hospital. J Nurs Care Qual 2006; 21: 223-229 (Pubitemid 44503753)
11. Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care 2002; 17: 86-94 (Pubitemid 34693847)
12. Missbach-Kroll A, Nussbaumer P, Kuenz M et al. First experience with a critical incident reporting system in surgery. Chirurg 2005; 76: 868-874 discussion 875
13. Hubler M, Mollemann A, Eberlein-Gonska M et al. Anonymous critical incident reporting system in anaesthesiology. Results after 18 months. Anaesthesist 2006; 55: 133-141 (Pubitemid 43288668)
14. Dominguez Fernandez E, Kolios G, Schlosser K et al. Introduction of a critical incident reporting system in a surgical university clinic. What can be achieved in a short term? Dtsch Med Wochenschr 2008; 133: 1229-1234
15. Brun A. Preliminary results of an anonymous internet-based reporting system for critical incidents in ambulatory primary care. Ther Umsch 2005; 62: 175-178 (Pubitemid 40403820)
16. Frey B, Buettiker V, Hug MI et al. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr 2002; 161: 594-599
17. Madzimbamuto FD, Chiware R. A critical incident reporting system in anaesthesia. Cent Afr J Med 2001; 47: 243-247 (Pubitemid 33795440)
18. Bartolome Ruibal A, Diaz-Canabate JI, Santa-Ursula Tolosa JA et al. Application of a critical incident reporting and analysis system in an anesthesiology department. Rev Esp Anestesiol Reanim 2006; 53: 471-478
19. Choy YC. Critical incident monitoring in anaesthesia. Med J Malaysia 2006; 61: 577-585 (Pubitemid 46569505)
20. Freestone L, Bolsin SN, Colson M et al. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care 2006; 18: 452-457 (Pubitemid 44823775)
21. Bowman L, Carlstedt BC, Black CD. Incidence of adverse drug reactions in adult medical inpatients. Can J Hosp Pharm 1994; 47: 209-216 (Pubitemid 24342495)
22. Wright M, Parker G. Incident monitoring in psychiatry. J Qual Clin Pract 1998; 18: 249-261 (Pubitemid 28552846)
23. Ahluwalia J, Marriott L. Critical incident reporting systems. Semin Fetal Neonatal Med 2005; 10: 31-37 (Pubitemid 40138864)
24. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl 2): ii3-9
25. Fox MA, Webb RK, Singleton R et al. The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 646-649
26. Currie M, Mackay P, Morgan C et al. The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 596-601
27. Webb RK, Currie M, Morgan CA et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 520-528
28. Thomas AN, Pilkington CE, Greer R. Critical incident reporting in UK intensive care units: a postal survey. J Eval Clin Pract 2003; 9: 59-68 (Pubitemid 36193625)
29. Reissner PSH, Tronnier V. Der Apotheker als Teil des therapeutischen Teams-Wunsch oder Realität? Krankenhauspharmazie 2007; 5: 6