[Clinical risk management. Implementation of an anonymous error registration system in the anesthesia department of a university hospital]

Abstract

Background: The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety.

Materials and methods: A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented.

Results: The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period.

Conclusions: Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).