TITLE: COMPUTERIZED ANESTHETIC INCIDENT REPORTING SYSTEM DETECTS REAL INCIDENTS

AUTHORS: Yoko Arakawa, MD, Eiichi Sato, MD, Yasuhiro Shimada, MD, PhD
AFFILIATION: Nagoya University School of Medicine, Nagoya, Japan.

Incident monitoring has been advocated as one of the means to improve anesthesia safety. However, low reporting rate and credibility of the reports are often debated.
The purpose of this study was to compare our computerized incident reporting system (CIS) and manual incident system (MIS) in terms of the reporting rate and reported /actual incident ratio.
METHODS: Since May 1996 to November 1997, we used a MIS by using a check-list type format and we mandated anesthesiologist to fill out the format after each case. Since December 1997 to the present, we have been using a CIS. The incident format is combined with patients' demographic and anesthetic format, and anesthesiologist are able to make these imputs in 5 min. The number of real incidents were calculated by reviewing the anesthesia charts for 4 months in each period.
RESULTS: During this whole period, 1295 incidents (12.4%) were reported in 9769 cases. There were 252 respiratory, 438 circulatory, 272 metabolic, 125 neurological, 86 trauma and 90 other incidents (involving machine troubles etc.). Critical incidents occurred in 32 cases. The rate of reported incidents increased from 9.2% in MIS to 16.1% in CIS. In MIS the number of the real incidents was 1.67 times the number of the reported incidents, while in CIS was 1.12 times.
DISCUSSION: We have found the CIS effective in reporting real incidents during anesthesia. However, the number of incidents stays stable during the study period and repetition of the same incidents are frequently observed. As a University teaching hospital where residents are rotating regularly, we need further process to use this incident reporting.