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The Anaesthesia Critical Incident Reporting System
Please feel free to enter incident data and share your experience using the following form

1. Team

Who is reporting ?
How have you been related to this anaesthesia ?
How have you been related to this event ?
To which profession does the responsable person of the event belong ?

(please choose the appropriate field out of the drop-down menue)

Team members directly present during occurance of the incident (check all appropriate fields)

MD-anaesthetist, non-resident 2. MD-anaesth., non-resident MD-anaesthetist, resident 2. MD-anaesthetist, resident
Nurse Anaesthetist 2. Nurse Anaesthetist
MD-surgeon, non-resident MD-surgeon, resident Surgical nurse, technician OR-nurse
Cardiac technician ER-nurse Other

Workload of the responsible provider of anaesthetic care or the person causing the event
hours on duty without sufficiant rest (if known)

2. Patient

Sex
male female		 Age
Years		 Intervention
elektive emergency
ASA Status
class I class II class III class IV  class V

3. Anaesthesia

Overall anaesthetic technique (please choose the appropriate field from the pull-down menue)

4. Incident

At what time of the day did the incident happen:  (1 - 24)

Where did the incident happen:  
(please choose the appropriate field from the pull-down menue)

What happened ?
Please describe the incident in your own words
(Case description up to the event) We would like you to be careful not to present data here, that could identify the patient, the team or the institution. Furthermore, if you wish to print out this report, please stay in between the margins of the text field.

Please describe the management of the situation in your own words.
(Case description from the moment of occurance on)

Please tell us if (and in case how) this event changed your clinical practice of future situations like this.

What led to the detection of the incident:

5. Outcome

Did the incident influence the outcome ? Definitive outcome (if known)
Yes No

6. Evaluation

What led you successfully manage the event (recoveries) ? (Please choose the most important factor)

personal factors ?

knowledge skills
experience situational awareness
use of appropriate algorithms

team factors ?

extraordinary briefing extraordinary teambuilding
extraordinary communication in the anaesthetic team extraordinary communication in the surgical team
extraordinary communication between both teams
system factors ?
additional monitoring or material replacement of monitoring or material
additional personnel replacement of personnel

Other startegies:

What would you suggest for prevention ?
(please choose the most important field)

additional monitoring or material improved monitoring or material
better maintenance of existing monitoring/equipment improved arrangement of drugs
improved arrangement of monitoring/equipment better training/education
better working conditions better organization
better supervision more personnel
better communication more discipline with existing checklists
better quality assurance development of algorithms / guidelines
abandonment of old 'routine' other (please specify below)

Other means for prevention:

Please answer the following question only, if you were the primary provider of anaesthetic care !!!

What led to the incident  (cause) ? (please choose the most important field)

personal factors ?
diminshid attention without lack of sleep diminshid attention with lack of sleep
illness in the team insufficiant knowledge
very high workload severe non-job stress
wrong planning no check (patient, material or drugs)
team factors ?
insufficiant coordination (Briefing) insufficiant teambildung
insufficiant communication in the anaesthetic team insufficiant communication in the surgical team
insufficiant communication between both teams
system factors ?
lack of personnel unfamiliar surrounding
time pressure because of possible hazards for the patient time pressure out of organisation reasons
technical problem

Other reason:

7. In general

In your opinion:
the incident was preventable the incident was not preventable

ALARM - report:
 this event should be communicated to the appropriate professional audience as soon as possible (for example letter to the editor of major resources in anaesthesiology)

8. Quality assurance

Would you have reported this incident even if the system would not have been anonymous (but certainly confidential) ?
Yes No
Was the filling of the form too cumbersome for you ?
Yes No		 Is the questionaire structured  ?
Yes No
Are the questions asked clear enough

 

9. Submit

Please check your answers again
If all answers are correct, please click on 

 

Do you have any suggestions for imptovement ?
Please send an email to: Sven Staender, MD