Experimentation of an anaestesiologic incident monitoring system in Emilia-Romagna Region (Italy) hospitals

Patrizio Di Denia, Rita Maria Melotti, Francesca Bova, Vania Basini, Renata Cinotti

Research output: Contribution to journalArticlepeer-review


Objectives: This study describes the experimental implementation of incident reporting in the anaesthesia services of Emilia-Romagna Region Hospitals. Its principal objectives are to assess the applicability and feasibility of this tool in a regional context, to sensitize theatre staff to acknowledge events that may compromise patient safety and to identify areas to be improved. Materials and method: The study is conducted by Emilia-Romagna Health Agency. It involves 44 theatre units of 16 regional "Aziende Sanitarie" (a trust that rules community services and hospitals). Theatre staff has been invited to spontaneously and even anonymously report incidents and near miss using a dedicated form. The tools arranged and offered to each Aziende Sanitarie were a training set for staff, a reporting form adapted to the anaesthesia context and an internet database to register the reported incidents. Results: In the first 5 months of the study (march 04-july 04), 173 reports of anaesthesiological incident were collected. In 62% of the cases accidents were reported by physicians; the incidents mainly involved patients with low anaesthesiological risk (ASA I/II, 56% of cases), submitted to general anaesthesia (68%), in the preoperative period (38%). In 15% of the cases the patient suffered of a damage; the most frequent events were classified as "inaccuracy or inadequacy" (34%); human errors were considered the most frequent cause (48%). Discussion: Despite the short observation period, preliminary results confirm that the incident reporting system brings useful information that can be used in high risk health services such as anaesthesia to identify areas to be improved.

Original languageEnglish
Pages (from-to)61-65
Number of pages5
JournalRevista de Calidad Asistencial
Issue number2
Publication statusPublished - Mar 2005


  • Anaesthesia
  • Incident reporting
  • Internet
  • Quality Improvement

ASJC Scopus subject areas

  • Medicine(all)


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