The voluntary risk reporting system CIRS
Another example from the clinic's everyday life: In a children's hospital, the breathing tubes in intubated babies repeatedly slipped out. After the reports of these incidents accumulated, a doctor researched and found out that a new, cheaper plaster was purchased. Unfortunately, it stuck badly, especially in intubated infants. Thanks to a reporting system, this vulnerability could be closed quickly.
This Critical Incident Reporting System (CIRS) is a reporting system for critical incident reporting in health care settings. In 2007, the Patient Safety Action Group issued recommendations for the general introduction of CIRS. The systems were originally used in engineering z. B. designed for airline pilots. Clinic and specialist doctors have had "CIRSmedical" since 2005, organized by the Medical Center for Quality in Medicine.
In November 2007, the Institute for Health and Medical Law (IGMR) of the University of Bremen and the AOK Federal Association presented the results of a project on the use of CIRS together with twelve children's hospitals. Around 1, 300 reports were collected during the project period at the stations and analyzed and evaluated by the IGMR. The results: "Critical events" in drug treatment were the focus at 35 percent.
Defects in the clinic
Clinicians - 73 percent of whom were nurses and 27 percent of physicians - reported drug preparation problems (61 percent), and 34 percent of prescribers and 5 percent of drug dispensers.
The second most frequent risk focus (24 percent) was the deviation from medical or nursing standards, followed by poor documentation (15 percent) and organization (9 percent). In the case of medication, typical risk situations in everyday clinical practice were confusion, interrogation, reading / calculating, as well as missing labeling of medicines.
It has been shown that the reporting system used can help uncover critical events, especially with typical routine action and long-established standards. It is less suitable for tracking down complex fault chains or for uncovering organizational deficiencies. Despite this limitation, CIRS is an effective tool for improving patient safety, as it can prevent the transition from error to harm.