Christian Hohenstein

Critical incidents during prehospital cardiopulmonary resuscitation: what are the problems nobody wants to talk about?

We wanted to identify incidents that led or could have led to patient harm during prehospital cardiopulmonary resuscitation. A nationwide anonymous and Internet-based critical incident reporting system gave the data. During a 4-year period we received 548 reports of which 74 occurred during cardiopulmonary resuscitation. Human error was responsible for 85% of the incidents, whereas equipment failure contributed to 15% of the reports. Equipment failure was considered to be preventable in 61% of all the cases, whereas incidents because of human error could have been prevented in almost all the cases. In most cases, prevention can be accomplished by simple strategies with the Poka-Yoke technique. Insufficient training of emergency medical service physicians in Germany requires special attention. The critical incident reports raise concerns regarding the level of expertize provided by emergency medical service doctors.

Critical incident reporting in emergency medicine: results of the prehospital reports

Background Medical errors frequently contribute to morbidity and mortality. Prehospital emergency medicine is prone to incidents that can lead to immediate deadly consequences. Critical incident reporting can identify typical problems and be the basis for structured risk management in order to reduce and mitigate these incidents. Methods We set up a free access internet website for German-speaking countries, with an anonymous reporting system for emergency medical services personnel. After a 7-year study period, an expert team analysed and classified the incidents into staff related, equipment related, organisation and tactics, or other. Results 845 reports were entered in the study period. Physicians reported 44% of incidents, paramedics 42%. Most patients were in a life-threatening or potentially life-threatening situation (82%), and only 53% of all incidents had no influence on the outcome of the patient. Staff-related problems were responsible for 56% of the incidents, when it came to harm, 78% of these incidents were staff related. Conclusions Incident reporting in prehospital emergency medicine can identify system weaknesses. Most of the incidents were reported during care of patients in life-threatening conditions with a high impact on patient outcome. Staff-related problems contributed to the most frequent and most severe incidents.

German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005–2015

BACKGROUND Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors. METHODS Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all. RESULTS Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure. CONCLUSION Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.

Beispiele umgesetzter Maßnahmen aus CIRS

Mit Hilfe eines Critical Incident Reporting Systems (CIRS) ist es moglich, uber Fehlerquellen und Systemschwachen in der praklinischen Notfallmedizin informiert zu werden. Dabei hat sich gezeigt, dass die anonymen Meldungen nicht nur in der Aviation, sondern auch in der Notfallmedizin zu Konsequenzen fuhren konnen und damit die Patientensicherheit erhohen. Hierzu gehoren beispielsweise das gemeinsame Lagern von Losungsmittel und Medikament oder Intubationsbesteck mit alternativem Atemwegsmanagement. Getrennte Lagerungen von Medikamenten, insbesondere der Narkosemedikamente, sind ebenfalls sinnvolle Masnahmen zur Erhohung der Patientensicherheit. Nationale und internationale Empfehlungen von Spritzenbeschriftungen sind unter anderem anonymen CIRS-Meldungen zu verdanken und werden zunehmend im deutschsprachigen Raum umgesetzt. Technische Veranderungen, die bestimmte menschliche Fehler unmoglich werden lassen (Poka-Yoke-Prinzip) haben teilweise Einzug auch in die Notfallmedizin erhalten, z. B. der routinemasige Einsatz von Ruckschlagventilen beim Infusionssystem.

Akuter Schlaganfall – Aufgabe für Notarzt oder Rettungsassistent?

Notfall Rettungsmed 2018 · 21:147–148 https://doi.org/10.1007/s10049-017-0398-z Online publiziert: 12. Dezember 2017

CIRS: Generelle Anforderungen an effektive Systeme

Critical Incident Reporting Systems (CIRS) haben sich als Teil eines Risikomanagements sowohl in der Aviation als auch in der Medizin bewahrt. Um das Potenzial eines CIRS voll zu nutzen, ist es neben der Implementierung einer einfach nutzbaren Webseite wichtig, die gemeldeten Zwischenfalle zeitnah zu extrahieren, anonymisieren, analysieren und letztlich allen Mitarbeitern gegenuber Veranderungen des Systems transparent zu initiieren. Ein Expertenteam bestehend aus verschiedenen Berufsgruppen hat die Hauptaufgabe, Moglichkeiten zur Pravention von den gemeldeten Zwischenfallen zu erarbeiten, die in der Folge umgesetzt werden. Teure und aufwandige Losungen werden in der Realitat aus Kostengrunden haufig nicht umgesetzt, gunstige und einfache Losungen sind meist realisierbar und gleichzeitig sehr effektiv.