[A structured case analysis from the Critical Incident Reporting System of the German Medical Association and the...

Reporting systems for near misses are necessary to improve patient safety. In Germany, different systems are publicly available on both a national and regional level or as systems related to various medical domains. In contrast with the British Registry, our reporting systems still lack systematic evaluation. Using the Open-Task-Process Model (OPT model) one case of CIRSmedical (www.cirsmedical.de) was selected for a systematic analysis.

Case 148384 reports on a patient with a tentative diagnosis of pulmonary embolism with an oxygen saturation of 71 %. The attending physician was ordered to leave the patient to participate in the daily team meeting. After 40minutes, the nurses transferred the patient from the emergency department to the ICU. The OPT model systematically checks the properties of all tasks in a given process and matches them to requirements or solving capacities of the task.

The analysis manifests some structural problems: Although the case was not very difficult (high priority, but a frequent problem), the solving capacities were not adequate in order to avoid errors. Since the physician left the patient, the loyalty toward medical standards and the team error correction activity were low. The team did not intervene to prevent the doctor from leaving his patient.

The OPT model allows for the analysis of both single cases and complete data sets of CIR systems and is able to disclose structural problems of clinical management.