Anaesthetists and Incident Reporting - a brief regional history
John Williamson
Australian Patient Safety Foundation, Adelaide
Purpose
An account of the adventures of Australian and New Zealand Anaesthesia with incident reporting, from 1979 to the present time.
Method
Description based upon first hand experience over 25 years.
Result
Anaesthesia incident reporting first appeared from Boston, USA in 1978.1 An early Australian application appeared from Townsville in 1985. Valuable articles by Currie and Morgan preceded a seminal meeting of interested anaesthetists in Flinders Medical Centre, Adelaide in 1987, convened by Professor Bill Runciman. In 1988 he founded the Australian Patient Safety Foundation (APSF), supported by a small "core committee" of five College Fellows scattered around Australia. Practical encouragement came from Dr Noel Cass, the late Dr Bill Crosby, Professor Ross Holland, Dr Pat Mackay and the late Professor Douglas Joseph. The original "Anaesthesia Incident Monitoring Study" or "AIMS" was developed, quickly attracting New Zealand colleagues. AIMS data, incorporating cognitive science advice, soon influenced:
- the disappearance of unrecognised breathing circuit disconnections;
- appropriate use of pulse oximetry, capnography and volatile agent monitoring, leading to earlier recognition of endobronchial intubation, gas embolism and vaporiser problems;
- a focus on system-based errors;
- developing concepts of data-based crisis management protocols.2
Electronic incident reporting is now being examined for possible Specialty-wide use.
Conclusion
Incident reporting in Australian and New Zealand Anaesthesia has contributed to an increase in Specialty-wide trust and in safety gains that are serving as an example in medicine.
Time of Presentation
Saturday 7 May 2005 1530-1700
References
1. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anaesthesia mishaps: A study of human factors. Anesthesiology 1978;49:399-406.http://qhc.bmjjournals.com/ 2005 (in press).
