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Related Concept Videos

Types of Reports II: Incident or Occurrence Report01:21

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Incident Reporting in Perfusion: Current Perceptions on PIRS-2.

Timothy W Willcox1, Robert A Baker2

  • 1Green Lane Cardiothoracic Unit, Auckland City Hospital, Auckland, New Zealand; and Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand.

The Journal of Extra-Corporeal Technology
|April 14, 2020
PubMed
Summary
This summary is machine-generated.

Perfusionists find the ANZCP PIRS-2 reporting system valuable, but defensive unit culture and fear of identification hinder incident reporting. Improving system ease and addressing cultural barriers are key for enhanced patient safety.

Keywords:
cardiopulmonary bypassincidentsperfusionreportingsafety

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Area of Science:

  • Cardiovascular Perfusion
  • Patient Safety
  • Incident Reporting Systems

Background:

  • The Australia and New Zealand College of Perfusionists' (ANZCP) Perfusion Incident Reporting System (PIRS-2) is an open-access online platform for reporting perfusion-related incidents.
  • PIRS-2 was updated to encourage learning from both adverse events and positive outcomes in unexpected situations.

Purpose of the Study:

  • To assess perfusionists' attitudes towards voluntarily reporting incidents and near-miss events to the PIRS-2 system.
  • To identify barriers and facilitators influencing the reporting culture within perfusion practice.

Main Methods:

  • A 9-question online survey was distributed via SurveyMonkey to 198 ANZCP PIRS-2 contact group members in August 2019.
  • Responses were analyzed, with results presented as percentages of total respondents and further broken down by region (Australia/New Zealand vs. non-ANZ).

Main Results:

  • The survey achieved a 49.5% response rate, with 95 practicing perfusionists completing the survey.
  • Unit culture (19%) and concern of discovery/identification (17%) were the most cited barriers to reporting.
  • While 79% of respondents had read shared reports, only 22% had submitted reports in the preceding 12 months.

Conclusions:

  • The ANZCP PIRS-2 system is perceived as relevant and beneficial for individual and team performance in perfusion.
  • Barriers such as defensive unit culture, ease of reporting, the 'fix and forget' phenomenon, and concerns about identification significantly temper the likelihood of incident reporting.