Dr Alexander Schleppers
Learn from other’s mistakes
Anonymous reporting to increase patient safety
Every day, critical events occur in hospitals but do not harm patients.
Today we know that, in most cases, these ‘near misses’ are not caused by lack of knowledge but a series of unfortunate incidents, for example, tiredness, distraction or poor organisation. Experts estimate about half of all the incidents are avoidable.
Although anaesthetics, for example, have never been safer than today, the German Society of Anaesthesiology and Intensive Care Medicine (www.DGAI.de) wants to increase patient safety even further. To this end the Society has introduced an anonymous reporting system aimed at reducing the number of ‘near-misses’ in hospitals. The Patient-Safety-Optimisation-System (PaSOS) records near misses and their causes, which are then analysed by a team of experts and the results and analysis are made available to all hospitals involved. ‘Each participant can learn from the others’ mistakes,’ explained Dr Alexander Schleppers, Medical Director at the DGAI. The system was modelled on those used in aviation, where analysis of near-misses has helped improve safety from some time.
The most important principle of the PaSOS system is anonymity. Each department employee (doctors or nurses) can report incidents, which are securely fed into the central system and anonymised so that no one can be called to account later for their voluntary information. The case study, inclusive of expert analysis, is then made available to other hospitals. The department where the incident was reported also receives feedback so that the cause of the near-miss can be eradicated quickly.
A good PaSOS can do more than just analyse incidents: Precise case analyses and the official feedback also increase pressure on hospital managers and medical equipment manufacturers to tackle existing problems. ‘This achieves more than a vague, verbal report,’ Dr Schleppers pointed out. ‘If the system discovers systemic errors it could lead to pur-poseful further training recommendations.’
The system, which only works if a large number of hospitals participate, is provided with information and training from a working party at the DGAI and BDA. To view and try this system go to: www.pasos-ains.de
This article was published on 05/01/2006