Taking note of what goes wrong and trying to prevent similar problems from recurring has always been an intrinsic part of any human endeavour. Lessons learnt in this way are passed on from teachers to trainees, either during 'on-the-job' supervision or in groups during mortality and morbidity meetings. The application of the critical incident technique, both to incident reporting as well as to anonymous incident monitoring, and the development of an occurrence classification system suitable for all health-care events, simply apply the same principle, but on a much larger scale. Incident monitoring allows us all to learn from problems encountered by others and provides information, particularly about uncommon events, that does not seem to be available in the same detail from other sources. For example, a search for vaporizer problems in the AIMS database, prompted by a media report of 'awareness', yielded 130 reports, of which half were human factor based. Analysis of these provided such compelling evidence for the use of in-circuit vapour analysis that this is to be introduced across the system in Australia at the beginning of 1997. Only a handful of relevant papers, providing a piecemeal view of only some of the problems (none human factor based), was obtained from a literature search. As a qualitative method, incident monitoring is viewed by many with some disdain. However, data yielded by this technique are very similar to those provided by more quantitative methods. Each of the methods for studying what goes wrong in health care has strengths and weaknesses, and each has a place in our armamentarium. Incident reporting is necessary, but has been underutilized as a source of information for improving the system. Incident monitoring, although voluntary, is an inexpensive, non-threatening way of improving the safety and quality of the health-care system. Both can be used, with a single instrument, to serve a national occurrence database which, together with information from other sources, will provide a rich bank of information currently not available in systematic form. The means exist to improve our practice, not only from individual experiences, but from the collective experiences of all who work in the system. The challenge lies in persuading people to add their own experiences to those of others.
ASJC Scopus subject areas
- Anesthesiology and Pain Medicine