Möglichkeiten eines CIRS in der präklinischen Notfallmedizin

 

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Zusammenfassung

Fehler gehören zu den 10 häufigsten Todesursachen in der Medizin. Die präklinische Notfallmedizin ist besonders anfällig hierfür. Auf der Suche nach den häufigsten Fehlerquellen sollte die 1. bundesweite CIRS-Datenbank für Notfallmedizin ausgewertet werden. 2005 wurde ein passwortfreier, anonymer Onlinefragebogen eingerichtet, über das Notärzte und Rettungsdienstpersonal Zwischenfälle melden konnten. Nach einer 7-jährigen Studienzeit wurden die Daten von einem Expertenteam mittels Root-Cause-Analysis ausgewertet. In diesem Zeitraum wurden 961 Fälle gemeldet und ausgewertet. Es konnten 10 wiederkehrende Systemfehler identifiziert und Präventivmaßnahmen formuliert werden. CIRS ist ein nützliches Instrument, um Systemschwächen zu diagnostizieren und entsprechende Veränderungen in die Wege zu leiten. Es gibt auch weiterhin großen Bedarf eines CIRS zur Fehleranalyse in einem Hochrisikogebiet wie der Notfallmedizin.

Abstract

Medical errors frequently contribute to morbidity and mortality. Prehospital emergency medicine is prone to incidents that can lead to severe consequences. We analyzed the first nation-wide critical incidents reporting system database to find out key errors and to develop preventive strategies. In 2005, a free internet website was set up with an anonymous reporting system for emergency medical service personal. After a 7-year period, an expert team analyzed the cases for reoccurring systematic weaknesses. 961 reports were entered and analyzed. Ten key issues were identified via a root-cause analysis and preventive measures formulated. CIRS is a powerful tool to identify weaknesses in prehospital emergency medicine and to suggest improvements. There is an ongoing need for CIRS to improve patient’s safety in a high-risk medical field such as emergency medicine.

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