To the Editor:—
We strongly support reporting systems and therefore read with interest the Editorial View by Auroy et al. 1However, before these methods become a standard audit or educational tool, some of their limitations must be considered further.
Clinicians can often select the type of adverse incident or outcome they will record. These tend to be those that are more severe, or those in accordance with individual perspectives of safety.2,3For example, prolonged paralysis after a regional block is more likely to be reported than transitory paresthesia. Temporary complications are often ignored, despite their potential educational value. Sometimes, reporters select those incidents most likely to carry a message to the organization’s management.4Incidents over inappropriate waiting times for patients or surgeons are not exceptional in anesthetic incident–reporting systems. Such selection and reporting biases may seriously distort perception of safety problems in anesthesia.
When reporting systems focus on near misses (prevented or mitigated adverse events), another difficulty arises, one familiar to aviation safety experts: information overload.4A progressively larger amount of data is collected and stored to be further analyzed. It can become increasingly difficult and costly to classify and retrieve meaningful events in such an extensive system analysis.5Gradually limited by resources and complexity, experts may end up fixing near misses instead of addressing system errors concealed behind the data overload. This may jeopardize the didactic value of such events.
Finally, anesthetic and medical practices in general are largely controlled by a professional body of knowledge.6Organizational guidelines and standards are much less the norm than, for example, in chemical or nuclear industries.7Variability in local practices, professional culture, and political context seriously challenge the generalizability of organizational analysis.
To address these problems, suggested approaches could include the use of international standardized definitions of incidents and the development of guided reporting through generic adverse event indicators. The specificities of the healthcare organization analyzed could also be more systematically described and addressed.
If limitations such as these are not well understood and properly addressed, case reports and root cause analyses of adverse incidents and near misses are likely to remain largely narrative and of limited educational value within the broader anesthetic community.
* Alfred Hospital, Melbourne, Australia. firstname.lastname@example.org