P14

IMPROVING INCIDENT REPORTING: WHAT ARE WE MISSING?

P. Moody, J. Blackburn, J. Swani, S. Ritchie-Mclean, M. Gandhi

Birmingham Children's Hospital, UK

Background/Context 

Like many UK hospitals, Birmingham Children’s Hospital has reporting systems for adverse events (IR1/DATIX) and excellence (IR2/”Greatix”). The APRICOT study[1] showed that many events occur during anaesthesia that require some intervention by the anaesthetist to prevent a potentially life-threatening emergency (e.g. mild laryngospasm responding to propofol), which may not be reported as IR1. Those involved might reflect on the event or discuss with colleagues afterwards, but learning may be confined to those directly involved.

Problem 

Many of the ‘lumps and bumps’ that occur during routine paediatric anaesthesia are undocumented, meaning that only those directly involved can reflect and learn from these events.

Strategy for change

We implemented a new "IR0" reporting system to work alongside the traditional IR1 and IR2 systems, to report these minor, inconsequential issues. This is easily accessible via QR codes on every anaesthetic machine, simple to use and mainly free-text to enable learning and reflection.

Measure of improvement 

A total of 51 events were reported on IR0 over the first 6 months. Most reports submitted offered important learning points, and these were presented to the department. However, there were also problems with IR0, specifically that most of the reports were submitted by a small number of individuals in the department, and that a small number of cases reported as IR0 should have been reported as IR1.

We surveyed the department to try to improve the IR0 form. Problems identified included length of time taken to complete the IR0, forgetting to do it or finding it hard to fit into a busy list, thresholds and grey areas between IR0 and IR1 reporting, definition of an ‘event’, consistency of recording some or all learning incidents, and uncertainty about where to report low/no harm incidents or near misses.  We therefore made changes to help more clearly guide users how to report on this novel system.

Lessons learnt 

The result of this QIP is a novel system of anaesthetic event reporting that is clearer, efficient and highly accessible. We hope that this will improve safety in paediatric anaesthesia through broader capturing of case-based learning points.  After the survey was undertaken, we have clarified the list of cases to be submitted to Datix/IR1, and which to report to IR0 for learning only, and have streamlined the form to make this clearer.

Message for others 

Managing the “lumps and bumps” of paediatric anaesthesia is part of the job of a paediatric anaesthetist, and despite individuals involved often reflecting or discussing these events with others, there is no opportunity for wider learning. Although still a work in progress, we hope that our IR0 project will help improve learning from anaesthetic events in the future.

Reference:

Engelhardt T, Ayansina G, Bell T, et. Acl. Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study). Anaesthesia 2018:74;300-311