Key incident monitoring and management (KIMMS) – results from 8 years of collecting data

Pathology ◽  
2017 ◽  
Vol 49 ◽  
pp. S72
Author(s):  
Tony Badrick ◽  
Stephanie Gay ◽  
Ken Sikaris
Keyword(s):  
Incident Monitoring

scholarly journals Recovery Room Incidents in the First 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 650-652 ◽  
Author(s):  
J. H. Van Der Walt ◽  
R. K. Webb ◽  
G. A. Osborne ◽  
C. Morgan ◽  
P. Mackay
Keyword(s):  
Pulse Oximetry ◽  
Recovery Room ◽  
Organ Damage ◽  
Adverse Outcomes ◽  
Recent Analysis ◽  
Respiratory Events ◽  
Malpractice Claims ◽  
The Central Nervous System ◽  
Incident Reports ◽  
Incident Monitoring

Of the first 2000 incidents reported to the Australian Incident Monitoring Study 120 (6%) occurred in the recovery room after general, regional or local anaesthesia. Over two thirds (69%) of these involved the respiratory system, 19% were cardiovascular, 3 % involved the central nervous system and 9% were miscellaneous in nature. These recovery room incidents were associated with significantly more adverse outcomes (56%) than incidents in the operating theatre (24%). The types and relative frequencies of these recovery room incidents were similar to those of serious recovery complications in a recent analysis of closed malpractice claims; this suggests that incident monitoring may be useful in the study and prevention of recovery room complications. Over three quarters (77%) of all recovery incidents (and 88% of respiratory incidents) were detected clinically; the remainder were first detected by a monitor. A theoretical analysis showed that over 95% of respiratory events, had they been allowed to evolve, would have been detected by pulse oximetry before organ damage occurred, emphasising the potential importance of pulse oximetry in reducing adverse outcome from any complication in the recovery ward which might be “missed” by clinical observation. The findings of this study underline the importance of having an adequate number of trained recovery nursing staff supported by the availability of a pulse oximeter for each patient at least until the return of protective reflexes and the ability to maintain adequate arterial saturation has been established.

Post-incident monitoring to evaluate environmental damage from shipping incidents: Chemical and biological assessments

2012 ◽  
Vol 109 ◽  
pp. 136-153 ◽  
Author(s):  
Jagoš R. Radović ◽  
Diego Rial ◽  
Brett P. Lyons ◽  
Christopher Harman ◽  
Lucia Viñas ◽  
...  
Keyword(s):  
Environmental Damage ◽  
Biological Assessments ◽  
Incident Monitoring

Introduction of a Prehospital Critical Incident Monitoring System—Pilot Project Results

2008 ◽  
Vol 23 (2) ◽  
pp. 154-160 ◽  
Author(s):  
Julian Stella ◽  
Anna Davis ◽  
Paul Jennings ◽  
Bruce Bartley
Keyword(s):  
Monitoring System ◽  
Major Trauma ◽  
Pilot Project ◽  
Structured Interview ◽  
Prehospital Setting ◽  
Near Miss ◽  
High Yield ◽  
Successful Implementation ◽  
Monitoring Process ◽  
Incident Monitoring

AbstractBackground:Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited.Problem:Implementation of an incident monitoring process in a prehospital setting.Methods:This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents.A project committee coded and logged all incidents and developed recommendations.Results:Of 4,429 ambulance responses, 41 cases were analyzed.Twenty-four (58.5%; 95% CI = 49.7–67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03–2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98–1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91–8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04–2.16). A total of 56 of 77 (72.7%; CI = 65.5–80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7–68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4–50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3–49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6–91.3%); in three cases (3.9%; CI = 3.7–4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5–2.7%); three cases resulted in remedial action (3.9%; CI = 3.7–4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9–5.5%).Conclusions:The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types.The large proportion of incidents in the “near miss” category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

scholarly journals Customer focused incident monitoring in anaesthesia

Anaesthesia ◽  
2007 ◽  
Vol 62 (6) ◽  
pp. 586-590 ◽  
Author(s):  
F. A. Khan ◽  
S. Khimani
Keyword(s):  
Incident Monitoring
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