Dr. Norbert Rose
Director of the Department of Quality Management
Specialist in General Medicine,
Medical Quality Manager, EOQ
Cantonal Hospital St. Gallen,
CH - 9007 Switzerland
Email: [email protected]
For references, please contact: [email protected]
The St. Gallen CIRS in the Meldeportal®: A Successful Error-Reporting System in Healthcare
Critical incidents and adverse patient episodes caused by avoidable and deficient processes or decisions are a daily occurrence in hospitals and other healthcare institutions. Doctors, nurses and other health professionals agree that everyone must learn from dangerous events to enable them to prevent their reoccurrence in the future. The question, however, is how this can be done.
The overriding objective must be to continuously reduce the number of catalysts and preconditions for errors or accidents, thereby precluding them from triggering an unsafe act. Studies in error theory show that the majority of accidents or errors occur when a series of failures take place in sequence (see Figure 1). As the possibility of an unsafe episode increases, so too does the likelihood of a manifest critical incident. By continuously assessing errors, it becomes possible to reduce the number of catalysts for errors and accidents and the frequency of critical incidents.
since 2002, Cantonal Hospital St. Gallen, Switzerland
Reporting systems such as the CIRS in St. Gallen Hospital provide an effective and appropriate tool for systematically developing improvement measures drawing on the information gleaned from events which had the potential to harm patients. Using a snowball system, the Cantonal Hospital St. Gallen has, since 2002, introduced 24 reporting groups throughout the hospital group (St. Gallen Cantonal Hospital, Rorschach Hospital and Flawil Hospital).
Since the introduction of the system, the number of reported CIRS events has doubled from 596 to 1,200 per annum. Increased reporting is not due to greater risk-taking in the hospital. On the contrary, as analyses have shown, growing confidence in the reporting mechanism has resulted in more staff using the system. The new culture of safety in the hospital is underpinned by a multi-professional and interdisciplinary conceptual approach, which is conspicuous in the manner in which CIRS reports are jointly discussed and reviewed by nursing and medical practitioners in all three hospitals using the St. Gallen CIRS (Figure 2).
Core Features of the St. Gallen CIRS
The introduction of a reporting system causes concerns among staff – some of which are tacit while others are explicit - that it will result in the imposition of legal or internal sanctions. These reservations, which were expressed in equal measure by medical and nursing staff, can be addres sed by giving a guarantee that reports will be made in confidence and that incidents of harm to patients are not reported on the CIRS.
The hospital must minimise the technical and formal obstacles facing those who wish to file a report. Difficulty accessing report forms will deter staff who will most probably forget the matter and return to their core activity. The St.Gallen “threeminute form” can be easily downloaded from the Intranet in just two clicks of the mouse. The volume of information required on a form impacts on the user-friendliness of a reporting system. Forms requiring more than 100 separate fields to be filled in have a deterrent effect which results in low reporting levels. The three-minute form used in St. Gallen is successful precisely because it requires only a small number of key fields to be filled.
The use of a CIRS allows some of those working in the hospital to realise that errors are caused by everyone involved in the investigation, treatment and care processes. Errors are pervasive in all parts of the organisational hierarchy and in all professions and disciplines and no one is better or worse that others in terms of making errors. Medical and care staff from all disciplines examine reported incidents with a view to finding solutions. Grounded in multi-professional, interdisciplinary approaches, this safety culture is an indispensable feature of the modern CIRS.
The experience of St.Gallen demonstrates the benefits of establishing a reporting system in a hospital or hospital group. The vast majority of reports relate to investigation, treatment and care processes in the hospital, clinic or discipline in question. Detailed knowledge of local conditions is, therefore, required to evaluate improvement measures.
As a reporting system underpinned by a functioning error culture becomes more established, the willingness to report serious incidents grows. Confidence in the system is also influenced by the profile of those responsible for the CIRS. The number of reports will increase if the person or persons receiving the reports on the CIRS system show sensitivity and social skills when performing the evaluation of the reports (Figure 3).
a Tool to Save Resources
Some of the reporting mechanisms in place in the German, Austrian and Swiss health systems are statutory systems (for instance, in the area of hae movigilance), while others have different origins (for example, the reporting of falls). Reporting an incident must be simple and unproblematic for the person reporting. For instance, a person who wishes to make a report is unlikely to search for very long for a form on the Intranet or Internet. For this reason, the St. Gallen Cantonal Hospital decided to develop a single reporting portal known as Meldeportal® to provide all reporting systems, statutory and otherwise. The Meldeportal® is easy to find on the Intranet and directs those who want to make a report to the appropriate reporting system.
The Meldeportal® (see www.meldeportal.ch) contains a number of reporting systems:
1. St. Gallen CIRS, the only anonymous reporting system for critical incidents.
2. Haemovigilance, a reporting system on risks before, during and after the administration of blood products (Swissmedic).
3. Material vigilance, a reporting system for incidents connected to medical devices (Swissmedic).
4. Pharmacovigilance, a reporting system for adverse drug reactions (Swissmedic).
5. Reporting Falls, a reporting system for all types of falls, whether by patients, relatives or staff.
6. Personal injury and damage to property, a reporting system for personal injuries and material damage.
7. Notifiable communicable diseases, reports to the Cantonal Chief Medical Officer or the Federal Office of Public Health concerning notifiable diseases (see Figure 4.)
in Other Healthcare Institutions
Experience shows that the St. Gallen CIRS concept can be uniformly implemented across the healthcare spectrum - from acute, psychiatric and geriatric hospitals to rehabilitation clinics to care homes for the elderly. The four core characteristics of the St. Gallen CIRS (see box, page 17) apply to all types of healthcare institution.