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Lernen aus einem Fehlermeldesystem in der Kinderintensivstation

Learning from a critical incident reporting system in the pediatric intensive care unit

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Zusammenfassung

Hintergrund

Das Erfassen von Fehlern und kritischen Zwischenfällen ist eine Voraussetzung für eine lernorientierte Sicherheitskultur. Viele Krankenhäuser haben ein Meldesystem für kritische Zwischenfälle („critical incident reporting system“, CIRS) implementiert. Anwendung, Nutzen und Einfluss des CIRS auf die Patientensicherheit sind jedoch häufig unbefriedigend geblieben.

Ziel der Arbeit

Wir stellen die Frage, was man in den letzten 10 Jahren gelernt hat, um ein CIRS möglichst optimal zu nutzen.

Material und Methoden

Dem „Yorkshire Contributory Factors Framework“ folgend wird der Nutzen eines CIRS durch konkrete Beispiele aus der neonatologischen und pädiatrischen Intensivpflegestation des Kinderspitals Luzern illustriert. Anschließend werden, basierend auf einer Literatursuche in PubMed (von Januar 2000 bis Dezember 2014) die notwendigen Faktoren und Konzepte für die erfolgreiche Nutzung eines CIRS definiert.

Ergebnisse

Eine positive Grundhaltung gegenüber Fehlern, eine hohe psychologische Sicherheit und die Überzeugung, dass ein CIRS nützlich ist, sind Voraussetzungen vonseiten des Mitarbeiters, damit Vorfälle gemeldet werden und ein Lernen aus Fehlern möglich ist. Eine systematische Analyse der gemeldeten Vorfälle, personelle Ressourcen sowie eine entsprechende Verbreitung der Resultate und Umsetzung daraus abgeleiteter Verbesserungen sind wichtige Faktoren vonseiten der Organisation. Mithilfe des CIRS sollen alle sicherheitsrelevanten Ereignisse erfasst werden. Deren Kategorisierung erleichtert die Identifikation, die Analyse und das Formulieren entsprechender Schlussfolgerungen. Für eine lernorientierte Sicherheitskultur müssen wir sowohl aus Fehlern als auch aus Erfolgen lernen.

Schlussfolgerungen

Sowohl Faktoren vonseiten des individuellen Mitarbeiters als auch vonseiten der Organisation sind entscheidend, um ein CIRS optimal zu nutzen.

Abstract

Background

To record and analyze critical incidents is of paramount importance for any organization dedicated to improving patient safety. Therefore, many hospitals have implemented a critical incident reporting system (CIRS). However, the impact, benefits and use of such CIRS systems on patient safety have often been reported to be unsatisfactory.

Aim

What have we learned over the past decade about the effective and optimal use of a CIRS?

Material and methods

Following the Yorkshire contributory factors framework, the potential benefits of a CIRS are illustrated with selected examples from the neonatal and pediatric intensive care unit. Based on a literature search in PubMed from January 2000 to December 2014 this article also describes critical factors and concepts for the successful use of a CIRS.

Results

A positive mind-set towards errors, high psychological safety and the conviction that a CIRS can be beneficial are important factors to encourage individual healthcare personnel to report critical incidents and learn from errors. On the part of the organization, adequate resources of personnel, systematic analysis of the reported incidents as well as dissemination of the results and implementation of safety improvement strategies are critical factors for the effective use of a CIRS. All incidents with potential relevance for patient safety should be reported. The categorization of the reported incidents facilitates the analysis and identification of relevant conclusions. As an organization dedicated to improve patient safety we have to learn from errors as well as from successes.

Conclusion

The successful use of a CIRS depends on the motivation of individual healthcare providers as well as on organizational features that encourage critical incident reporting.

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Authors and Affiliations

  1. Neonatologische und pädiatrische Intensivpflegestation, Kinderspital Luzern, Spitalstraße, 6000, Luzern, Schweiz

    M. Stocker & T.M. Berger

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  1. M. Stocker
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  2. T.M. Berger
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Correspondence to M. Stocker.

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Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Stocker, M., Berger, T. Lernen aus einem Fehlermeldesystem in der Kinderintensivstation. Anaesthesist 64, 968–974 (2015). https://doi.org/10.1007/s00101-015-0111-x

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