Critical Incidents, QA

Training and Management of Critical Incidents

David Gaba and his team from Stanford introduce the concept of crisis resource management in their ACRM course. They use a CAE patient simulator.

The APSF (the Anesthesia Patient Safety Foundation) has published guidelines for the response to adverse events during anesthesia care and provide an electronic version of the APSF newsletter.

Simulators used in Anesthesia

Simulators are already quite frequent in use. The Department of Anesthesia at the University of Basel uses a Sophus simulator to evaluate and train operating room teams in a highly realistic surrounding.

Stanford University’s School of Anaesthesia have an active simulator program. focusing on Crisis Resource Management.

The University of Rochester Medical Center developed one of the first anesthesia simulators.

Critical Incident Reporting

The ASA runs a project on the analysis of closed claims in anesthesia.

Webb and Runciman’s Australian Patient Safety Foundation was based on an incident reporting system they developed to record anaesthesia incidents – the AIMS study. They provide and extensive database of critical incident related articles and reviews of the collected data. Legal confidentiality and privilege issues are vital to the collection and analysis of critical incident data.

Anonymous reported cases can be reviewed at the page of the Critical Incident Reporting System (CIRS) run by the University of Basel Department of Anaesthesia.

Critical incidents in daily anesthetic practice can be reported anonymously using the Critical Incident Reporting System (CIRS) form of the University of Basel Department of Anaesthesia.

Critical Incidents in Aviation / Human Factors

Probably the best page to start with all the Crew resource management stuff and human factors in aviation and medicine is the NASA/University of Texas/FAA-Funded Aerospace Crew Research Project. – publications list here.

Recently they have been working on human factors in medical error and critical incidents.

The US Govt Patient Safety Network has a very significant collection of important information and resources.

The critical incidents happening in aviation is run by the Aviation Safety Reporting System. They also provide an interesting monthly newsletter, Callback, providing information and comments on these incidents.

Crew Training International provide training services to a wide range of military and commercial air services.

Quality Assurance in Anesthesiology

Quality improvement in Anaesthesia is usually implemented at Department level. Examples include the University of Rochester.

The Australian College of Anaesthetists provide a PDF Guidelines for Quality Assurance in Anaesthesia.

The US ASA has been working on a quality assurance system.

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