Changing the culture: increasing captured intraoperative anaesthesia-related safety events through targeted interventions.

Abstract

Background: There is an under-reporting of anaesthesia-related safety events.¹⁰ Incident-capturing systems (ICSs) are essential for patient safety monitoring, identifying risks and ongoing opportunities for improvement. After a literature review and assessment of our current ICSs, we concluded that our institution lacked a reliable anaesthesia-specific ICS system, leading to under-reporting of anaesthesia-related safety events.

Methods: We conducted a quality improvement initiative to help increase perioperative safety event reporting by anaesthesiologists, fellows and certified registered nurse anaesthetists. We analysed all anaesthesia-related perioperative safety events from July 2019 to December 2020 to determine a baseline rate of safety events captured. We conducted a simplified failure-mode effects analysis and designed a key driver diagram to guide our initiative. Based on these, we designed and implemented seven interventions aimed at increasing anaesthesia-related perioperative safety event reporting. We then reviewed perioperative safety events captured from January 2021 to February 2023 and compared the safety event capture rate to baseline.

Results: Over 10 months, we trialled and implemented multiple interventions aimed at increasing perioperative anaesthesia-related safety event capture, including re-education, strategic placement of report forms, education of anaesthesia and non-anaesthesia personnel, celebration of events captured, promotion of a safe-capture culture where reporting was not seen as punitive and the transition to an online anaesthesia ICS. Over 25 months, we demonstrated a sustained increase in event reporting from a baseline of 1.9 incidents captured per week (average of 1000 cases performed weekly) to 19 events captured per week postinterventions.

Conclusions: Increasing event reporting required a multifaceted approach-ongoing attention to reporting barriers and developing targeted interventions promoting sustained reporting. Education on the importance of reporting, creating a reliable electronic ICS, creating a non-punitive culture and continuing to promote a safety culture contributed to system improvement.