Critical incidents

A safety information system (SIS) has been used at all Hirslanden hospitals since 2008, offering employees in all occupational groups the chance to file anonymous reports about mistakes that might have led to harmful incidents, and thus establishing a constructive error culture.

SIS is based on the statistical knowledge that every actual harmful incident is preceded by several hundred so ­called critical incidents. Reported cases are recorded and categorised in the Critical Incident Reporting System (CIRS), before being analysed and processed by an interdisciplinary committee. This analysis  is centred on two questions: “Why did the system allow this critical incident to occur?” and “How can the system be modified or amended to prevent the same critical incident happening again?” To ensure that they can mutually benefit from their experiences and insights, regular SIS meetings are held at which Hirslanden hospitals can present and discuss their own cases and resultant preventive measures among each other.

Particularly complex CIRS cases that also have a high learning potential are analysed in more detail. A cause­-and­-effect diagram (also known as the Ishikawa method) is used here for systematic incident analysis. The goal is also to learn as much as possible from potential incidents.

If a particularly complex CIRS case arises that needs to be analysed in more detail, senior management assigns the task to a specialist analysis team that is set up for this purpose. This team examines the case according to a wide range of factors, such as the patient factor, the institutional framework and the work environment. The first allocation of possible erroneous actions to these different factors is already made when studying the patient documentation. This is followed by interviews with the persons involved. At the heart of the analysis is the personal interview, where further potential incidents are uncovered – including those that are only latent in nature.

When analysing CIRS cases, a distinction is made between erroneous factors and the incident itself. For example,

two patients with the same name is a potentially erroneous patient factor. The resulting incident would be if the wrong patient were then brought for an x­ray. All erroneous factors that are uncovered are then linked to at least one fundamental countermeasure, which is scheduled accordingly with responsible persons assigned to it.

The advantage of the Ishikawa method is that it offers a structured appraisal of complex patient cases. With the relevant medical knowledge, the method is also easy to learn and enjoys wide  recognition. A possible disadvantage is the human factor involved – the method requires complex medical knowledge, together with excellent social skills and empathy. As mentioned above, the Ishikawa method is only applied in the event of particularly complex CIRS cases that also have a high learning potential – this is due to the amount of work involved in implementing the method.

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