i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
j o u r n a l h o m e p a g e : w w w . i n t l . e l s e v i e r h e a l t h . c o m / j o u r n a l s / i j m i
Incident reporting schemes and the need for a good story J. Rooksby , R.M. Gerry , A.F. Smith
a Computing Department, Lancaster University, UKb Department of Work, Organisation and Technology, Lancaster University, UKc Department of Anaesthesia, Royal Lancaster Infirmary, UK
Incident reporting is a central strategy for improving safety in the NHS (UK National Health
Service). In this paper we discuss incident reporting in anaesthesia. We discuss four schemes
for reporting: longstanding, departmental based schemes; newer, hospital wide schemes;
a national scheme; and an inter-departmental scheme (developed by the authors). We also
discuss an example report. We argue that this example report gives an expert ‘story’ of
an incident, describing the incident in a way that is useful for the practical activities of
maintaining and improving safety. We argue that stories are told and retold in reporting
schemes. The reporting schemes are not just there to collect data but to afford the stories
of what went wrong. In turn these schemes must be afforded stories by the anaesthetists,
safety managers and the organisation at large. We consider how schemes can be designed
to afford a ‘good’ story, one that is useful for the maintaining and improvement of safety.
2006 Elsevier Ireland Ltd. All rights reserved. Introduction
Disasters such as a patient death are extreme examples
of an incident and although lessons should be learned from
Incident reporting is a core requirement for NHS (UK National
these, the ethos of a reporting scheme is to pick up the little
Health Service) organisations in efforts to improve patient
incidents such as dysfunctional equipment, unmanageable
safety. Incident reporting schemes are socio-technical sys-
situations, and (often harmless) mistakes, and to address
tems and every such scheme is different in implementation
these so as to circumnavigate disasters In the aviation
and use. In their comprehensive review of the literature sur-
industry (the first industry to adopt incident reporting),
rounding technology related adverse events in healthcare,
eom British Airways shows a correlation between
Balka et al. to the differences between incident report-
high levels of incident reporting with reduced levels of high
ing schemes, particularly the lack of definition regarding the
and medium risk events that actually occur. Disasters, or inci-
scope and nature of adverse events, as the major barrier to
dents involving patient distress or harm are usually caused
extrapolating meaningful data from them at a national or
by a combination of smaller issues, have early warning signs
international level. They recognise the potential benefits of
or involve repetitions of mistakes or issues that have arisen
large-scale analysis of incident data, but point out that in
before Incidents are systems issues, not a chain of
doing so the situatedness of medical practices can be over-
events resulting from a failure and leading to an incident.
looked and incidents wrongly conceptualised as device or user
Non-systems models are limited in their ability to account
problems. Balka et al. suggest “new forms of governance may
for the incident and support the improvement of safety
be required, that place greater emphasis on socio-technical
Reporting schemes are soft systems. They are practical
approaches to improving safety in the day to day practices of
∗ Corresponding author. Tel.: +44 1524 510348.
1 Reported by the National Patient Safety Agency
1386-5056/$ – see front matter 2006 Elsevier Ireland Ltd. All rights reserved.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
work in healthcare that are themselves soft. We understand
sites and the launch of the NPSA (National Patient Safety
incident reports, not as mirrors of what went wrong, but as
Agency) national system. An iterative, multi-round approach
constructions that make active sense in the practicalities of
was taken to gain a picture of incident reporting schemes
improving safety. This construction we say is a ‘story’, and
as they unfolded and to involve the anaesthetists closely in
we say a reporting scheme is for the telling and re-telling
the design of the prototype, which was designed to suit their
of stories to improve safety. We are particularly interested
requirements. This work has taken place in the context of a
in how information technologies (including both paper and
much wider study (by the second author) into clinical gov-
computer) support reporting schemes and how these can be
ernance in the NHS, including of incident reporting in other
better designed and organised. From an IT design perspective
we look at how incident reporting schemes afford and areafforded stories. 2.2. What is an incident?
An insightful definition given to us by one anaesthetist is
Incident reporting in anaesthesia
of an incident as an “‘Oh S***!’ moment”. The official defini-tion from the NPSA (National Patient Safety Agency) is “Any
Incident reporting in the NHS is usually seen as a hospi-
unintended or unexpected incident which could have or did
tal wide, if not national issue. As such, incident reporting
harm one or more patients receiving NHS funded healthcare.”
schemes being implemented are hospital wide and national.
To apply such definitions in practice is subjective. When
We acknowledge that large-scale analysis of incident data
there has been actual harm to a patient, then events sur-
would be extremely beneficial to the improvement of safety,
rounding that harm can normally be thought of as an inci-
but our work has not been driven by that goal. In this paper we
dent, although there may be exceptions to this, for exam-
look directly at incident reporting in anaesthesia, at the issues
ple a patient or a surgeon may perceive harm (such as dis-
that anaesthetists face in reporting and how their reports are
tress) where the anaesthetist does not. It is when there is
used in the small scale to maintain and improve everyday
potential for harm that the answer to what is an incident
safety. We treat incident reporting qualitatively; as Short et
becomes more subjective. Some anaesthetists will see poten-
al. out, incident reporting schemes themselves are a
tial for harm where others do not, and some are more will-
form of qualitative research. We are interested in the practi-
ing to write a report. Writing a report is time consuming
cal aspects of reporting and learning from reports, and thus a
for a busy anaesthetist. There are some anaesthetists who
focus on the work of clinicians rather than that of their man-
might never report and others who are quite keen. Reports
agers and administrators is desirable.
by the keen include issues well beyond personal mistakes, for
Anaesthesia is the largest single hospital specialty in
example we saw reports concerning incorrect defaults set on
the NHS, with anaesthetists seeing around two thirds of all
admitted patients. Incident reporting has become a con-
There are also sensitive and controversial issues in report-
tentious issue in anaesthesia. There has been a longstanding
ing. Someone other than those involved in an incident can
tradition of incident reporting in anaesthesia (it being the first
write reports. Anaesthetists have referred to the possibilities
profession in healthcare to introduce incident reporting) and
for victimisation, but state the opposite is usually true where
attempts to impose new schemes have been disruptive. The
anaesthetists are unwilling to write reports about a colleague
older schemes were owned and organised by anaesthetists.
whose practices may be unsafe. Anaesthetists were indig-
Newer schemes have a managerial and legal emphasis and
nant that reports in the new hospital wide systems can be
are intended to be standard across hospital departments. By
written by anyone and referred to reports written by nurses
taking incident reporting in anaesthesia as our standpoint
and in one case by a cleaner. They felt these others did not
we are looking to the expertise and experience anaesthetists
understand their work and what is safe practice. A more
common issue is that some anaesthetists will ‘axe grind’against equipment they would like replaced, or write reports
2.1. Fieldwork
that in some way might enable them to gain new funds orequipment.
This paper is based on findings made in a study of incident
We have addressed when an incident is perceived, but
reporting in anaesthesia and the production of a prototype
we should also address how an incident is perceived. The
system to share reports between anaesthetics departments in
author of a report must describe what lead to an incident
different hospitals in the Northwest region of
and how it was handled, and describe what lessons might be
project involved three rounds of semi-structured interviews at
learned. Anaesthetists prefer a systems view of incidents, and
five hospitals about incident reporting, a validation workshop
this view is one echoed by the NPSA. Anaesthesia employs
for the system and observations of an anaesthetist at work
both applied and tacit knowledge incidents are not
and of audit meetings at two anaesthetics departments. The
simply misapplications or non-applications of knowledge but
prototype system was in use over 6 months. The period of
breakdowns in the tacit “patient-machine-anaesthetist col-
study coincided with the implementation of CNST (Clinical
lective” We can see such systems thinking in the
Negligence Schemes for Trusts) standard reporting at several
example report that is given later. This systems thinking isnot shared by all: anaesthetists complain that reports can beused (by managers) to blame ‘the last person who touched the
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
2.3. What is a reporting scheme?
ics department, but all that we have seen retain lightweightclassification and one half to one third of the form is for free
Reporting involves particular information technologies such
text. These forms will be placed in easily accessible locations.
as paper, databases, PowerPoint slides, spreadsheets, pens
Completed reports are posted into a box to be collected later
and mailboxes; they involve human actions such as writing
by an anaesthetist acting as audit manager. These reports
reports, analysing and discussing reports and summarising
are sometimes furthered analysed: at one site the audit man-
reports; there are guidelines and rules; and there are organi-
ager further categorised reports and entered these categories
sational provisions for reporting and an organisational culture
into a spreadsheet, at another a key phrase about the inci-
in which reporting takes place. The reporting scheme is the
dent was listed. Reports would be discussed at audit meetings,
organisation of many parts and processes. A useful reporting
often having the author of the report recounting what hap-
scheme will be organised in a way that promotes safety, but
pened (and not necessarily reading from the incident form).
not all reporting schemes can be said to be as useful as is pos-
The anaesthetists would discuss the issues raised by the inci-
sible in this way. In this paper we give an example report, but
dent and if necessary plan further actions to resolve these.
we emphasise that it is part of a wider process in which an
Reports may then also be re-written as a narrative summary
incident is interpreted and reinterpreted and perhaps acted
in the minutes of that meeting. Paper is a convenient medium
for anaesthetists to initially report on, and reports are often
A reporting scheme is more than the technologies of report-
later typed up in some way. The RCoA provide software for
ing, and is not about making factual accounts that mirror
reporting, but it is difficult to use and modify.
incidents. There is not a direct correspondence between an
As described, the departmental schemes are successful but
incident and a report: the report is a subjective account of the
imperfect. They are successful in that they are routinely used
incident, and in turn the report is never static. The incident
and they have a noticeable effect on patient safety in that
is told and re-told through reports, through analysis and cat-
anaesthetists are able to determine their own problems and
egorisation and through discussions in meetings. Actions to
go about solving them. However the system does not allow
maintain or improve safety come after analysis and discus-
the solving of problems that lie externally to the department
sion, but as we will explain with an example report, the main-
and relies on this problem being communicated to a person
tenance of safety often comes about directly through having
or system that may or may not exist. The system is also open
a discussion and thus learning and reinforcing knowledge.
to abuse in terms of not reporting, or over reporting. Anaes-
There are three schemes that we have encountered in our
thetists also find it time consuming to run.
study, and we discuss these together with a fourth schemethat we have introduced ourselves as an experiment. During
our study we found each department to have slightly different
The second scheme we describe, we term the hospital wide
implementations of the schemes, but rather than concentrate
scheme. This scheme is being introduced to all departments
on these differences we shall address the similarities between
studied. This scheme was initiated by requirements from
the schemes as implemented. At the beginning of our study,
each department was running schemes in parallel. At each site
The hospital wide schemes are run across all hospital
the older schemes were being phased out. This was completed
departments. Often a large paper form is required to be filled
by the end of the study at one site, but only after a series of
in, but in others a computerised form. These forms ask for
troubles with the first attempt aborted. We now describe the
detailed information and are reliant on categorisation. Ability
four reporting schemes. Following this we will discuss a spe-
to enter free text is limited: one form asks “please describe
what happened in detail” but offers a relatively small spacein which to do so; another gives a larger space but asks for
“clear, one sentence ‘good’ and ‘bad’ facts”. Two carbon copies
The first scheme we describe, we term the departmental
are made with each paper form, with at least two of the three
scheme. The departmental scheme is the oldest scheme, and
total copies going to managers. Anaesthetists were generally
was used at each anaesthesia department in the study. This
reluctant to use the hospital wide systems. Anaesthetists are
scheme is quite longstanding, and was running in parallel to
required to write reports on the hospital wide system, but
the second scheme we describe at each study site and is/was
found more value in the departmental system and tended to
use them both in parallel. At one site anaesthetists had regu-
The departmental reporting schemes are based on recom-
lar meetings with the clinical risk manager to discuss hospital
mendations by the RCoA (Royal College of Anaesthetists) who
wide reports but at others they received little or no feedback.
provide a standard paper form, and software for reporting. The
Anaesthetists would use the external system only when they
paper form is printed on one side of paper with a list of cate-
had to, believing their reports to be interpreted negatively and
gories of contributing factors on the reverse. The form asks for
used to blame them. One anaesthetist claimed that anyone
five short items of information (e.g. reporter’s name), has four
writing a lot of reports would be seen as unsafe, and their job
multiple-choice questions about the incident (e.g. severity),
and allows up to six categories to be chosen from the reverse.
At the site most advanced in its implementation, the exter-
Just under half of the front page allows free text to be entered
nal scheme was fully realised by the end of the study. This
under the headings: “Please describe what happened” and
was only after an aborted first attempt and a great number
“How do you think this might be prevented from happening
of difficulties, as an anaesthetist from the site explains: “The
again?” The form is often modified for use by an anaesthet-
Trust introduced their own scheme and banned use of the
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
existing (departmental) system. The new forms were badly
tain educational value and that it affords trust within the user
designed and we had little or no feedback. Rates of report-
community. To integrate with existing practices, and exist-
ing fell to about 10% of what they were previously. After much
ing reporting schemes, it was seen as inappropriate to expect
protesting, the Trust system was dropped and the (departmen-
primary reporting to be done on the new system, but rather
tal) system restarted for 3 or 4 months. Six months ago an
that reports could later be typed up or cut and pasted into
improved Trust system was implemented and this has been
it, perhaps after presentation and discussion at a meeting. It
working well for the last 4–5 months. They use forms we recog-
was also noted that web and email use by anaesthetists was
nise and there is now a feedback loop, whereby reports are
occasional, so a lightweight notice board rather than a discus-
discussed at audit meetings and then emailed to all the clin-
sion forum was the most suitable style of presenting reports.
ical staff. There is now also a full time audit manager in the
The system was in no way intended to replace the existing
Trust. Managing audits was taking about 3 h a week of my time,
systems, but to complement them. To maintain educational
which was too much. I have retained a role in coordinating
value, we provided a means for anaesthetists to report what
audits but the manager has taken over most of the work”.
they thought was useful, and a means to discuss reports online
The external schemes have their strengths in that they
or download them for discussion in meetings. To maintain
allow a hospital wide approach to safety, and they use full time
trust we allowed anonymous reporting, and provided a fea-
managers rather than taking up time of clinicians. However,
ture to show exactly who had access to the system. The system
these schemes have in several cases been badly implemented
was basically a secondary reporting scheme in which reports
and run more so because clinicians are required to report than
deemed as interesting by an audit manager can be cut and
they see value in it. Schemes of this kind are viable, and anaes-
pasted in, and were then available for reading and comment by
thetists are not against the idea of a hospital wide scheme in
a known group of users. Anaesthetists participating in design
principle. The problems of the schemes are associated with
agreed upon a reporting form similar, but more lightweight,
a disregard for the needs of anaesthetists in their day-to-day
working practices, and their concerns for control and profes-
This system has served as a means of gathering data and
sional status in their work. The site described above has shown
testing hypotheses. Anaesthetists told us that they liked the
that these schemes can be made to work well.
system, and that it contained reports useful to them. However,the system did not live beyond the project. As one anaesthetist
explained “Falling in love is easy but staying in love is the
The NPSA (National Patient Safety Agency) was set up in
problem, and I think that’s true about starting off and trying
2001 to improve the safety of patients by promoting a culture
to keep going. . . Its one of those things everyone thinks they
of reporting and learning from patient safety. The National
ought to do [but it] never quite seems to happen.” There are
Learning and Reporting System is central to their strategy
several reasons that could all account in some way for why the
with the intention of using it to identify trends and patterns
system was not adopted by the anaesthetists. These reasons
of avoidable incidents and their root causes; develop mod-
being that the system failed to gain a champion to encour-
els of good practice and solutions; to provide feedback and to
age reporting, that the level of ‘useful’ reports did not reach a
support education and learning. The NPSA also provide train-
critical mass, that the anaesthetists spent limited time with
ing in root cause analysis to investigate incidents. As well as
computers and that the uncertainties and problems surround-
providing the system and training they also promote steps
ing the other reporting schemes meant anaesthetists were
towards improved safety building a safety cul-
reluctant to report into any system. The anaesthetist quoted
ture, communicating and learning lessons. They see errors as
above went on to state “I think it’s a missed opportunity”. The
having a system of causes, and oppose a blame and punish-
anaesthetists involved in the study believed that reports could
ment culture. They encourage a circle of safety that begins
be usefully shared, and the design of our system for doing so
with reporting, goes through the management of the safety
The National Reporting and Learning System was rolled out
2.4. An example report
during 2004. The system was not in use at any study site dur-ing our fieldwork. The anaesthetists at each study site were
Incident reports in anaesthesia can be made in up to four dif-
well aware of the NPSA but did not know anything specific
ferent systems, with reports usually being duplicated. This
about what the NPSA might start doing at the national level
can be wasteful, but because of the different purposes and
and when. We largely agree with the NPSA’s portrayal of inci-
uses of each system, straightforward integration is not pos-
dents but, at the local level, they seem to lack the power of
sible. British Airways uses two reporting systems, but this is
the insurers who have their own requirements for incident
by design and is used to handle more sensitive ‘human fac-
tors’ separately from other issues t remains as a futurestudy to compare reports of the same incident in the differ-
Reporting scheme 4: inter departmental
ent systems described in this paper, but it is likely that while
Reports that are discussed in one anaesthetics department are
the ‘facts’ remain the same the meaning and significance is
not usually shared with anaesthetists in different hospitals.
changed. It is a difficult task to collect different reports of
Seeing value in a system to do this, we produced an online
the same incident, and for the time being we have gathered
reporting system designing it around four main require-
unconnected reports made on all systems except the national.
ments: that it should integrate with existing practice, that it
In this paper we will present one report, taken with permis-
should integrate with existing reporting schemes, that it main-
sion by the author from the inter-departmental system. We
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
have interviewed the author of the report about the meetings
how to deal with the error. The first two lessons involve the
in which it was discussed, and the processes that it triggered.
importance of the appearance of syringes for distinguishing
The report concerns a serious incident that involved a mis-
between different drugs. The third lesson is that in unusual
take in administering drugs that lead to patient harm. This
circumstances the anaesthetist must be extra vigilant. The
report is less mundane than some, although fairly typical.
first two lessons are relevant to procedure and are therefore
Most interviewees cited it as the most interesting report on
relevant to the management of safety. The process here can
be improved to improve safety. The third lesson is one of edu-cation for anaesthetists.
This was a serious incident that led to a patient com-
plaint. The anaesthetist involved was at the only hospital in
our study where anaesthetists had a good relationship with
the risk managers and the anaesthetist in question told us
they did not feel blamed for the error in any way. An inves-
The incident caused: 3: Transient abnormality with full
tigation had been launched following the reporting of this
incident in the hospital wide system, and changes to proce-
How preventable do you think the incident would be by fur-
dures and visual information were apparently being consid-
ther resource? 1: Probably within current resource
ered. The report of this incident in the departmental system
lead to discussion of how anaesthetists can avoid this kind
The patient was for direct pharyngoscopy, a short but stimu-
of mistake, including how the system might be improved,
lating procedure so the plan was to use boluses of alfentanil
but also sharing the lesson about vigilance. There was also
and mivacurium. Both these drugs were in correctly labelled
discussion of this report on the inter-departmental system,
10 ml syringes. Inadvertently I gave the mivavurium prior to
saying that similar problems had occurred at other sites.
induction instead of alfentanil. I did not realise my error for
The report then does not simply disclose an error or mis-
a few minutes. The patient initially appeared drowsy but agi-
take, but provides a story that can be discussed, interpreted
tated, breathing became shallow and saturation dropped to
and acted upon. An important part of maintaining safety
85%. He developed multple VEs. On realising my error some
is through actual discussion of the report, educating anaes-
propofol was given, the trachea intubated and over a short
thetists about how the issues affect their day to day working
period of time his saturation and ECG returned to normal.
We continued with the procedure. On recovery he had recallof what had happened and was quite distressed by it. Discussion—the need for a good story
To conclude this paper we consider design issues for reporting
1. Correctly labelling syringes isnt enough, especially when
schemes. Our argument is that a report is not about hav-
the colour of the labels is very similar. In this case both
ing data but about allowing an anaesthetist to discuss and
the labels that come with the drug are white. We use
consider what happened and what lessons can be learned.
other visual aids first, syringe size probably being the most
Reporting, we believe, can be likened to storytelling. We will
consider the report as a story and then consider how exist-
2. Avoid drawing up muscle relaxants and induction agents
ing reporting schemes afford these stories and how they do or
in similar size syringes at the same time as other drugs, ie
can better afford good stories for maintaining and improving
sux and fentanyl, thiopentone and augmentin.
3. In this case the part the cause for the error was that I was
using a number of drugs that I dont usually use - thats when
3.1. The report as a story
Berg the medical record as an active mediator
The report begins with some standard information. This
in care rather than a mirror of what happened; Similarly, the
gives the reader an orientation to the report and provides
incident report does not give the raw facts about an incident
standard terms for storing and analysing the report. A more
but recreates the events and existents (the things), and gives
surprising reason that anaesthetists gave for wanting this
evaluation and opinion in a way that is meaningful to the
standard information was that when writing reports, it gives
maintenance and improvement of safety. To aid discussion
them somewhere to start, and allows them to start thinking
of this issue, we consider incident reporting as storytelling.
Previously, Rooksby and Kay ve looked at how work is
The first paragraph gives the story of what went wrong. The
retold in radiology reports in an idealistic, but more mean-
scene is set with the surgical procedure and the anaesthetics
ingful way for further work. We do not use the term story
procedure, with a statement that the procedure began with the
to somehow diminish the truthfulness or expertise that goes
correct drugs. The events are then given, beginning with the
into reporting in medicine, but take it as a concept that brings
complicating error and ending with the two part resolution:
with it particular analytic possibilities. Storytelling has been
firstly about how the ECG was returned to normal and secondly
found to be a particular way that experts form and com-
municate information, for example engineers use stories to
The second paragraph concerns the lessons learned. The
three lessons concern the procedure of using drugs, and not
systems designers in health use stories to discuss success
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
and failure of systems scientists in the Life Sciences
Anaesthetists do their best to write meaningful content, and
use stories to communicate between themselves
time and labour is involved in the writing, re-writing and pre-
records in primary care have also been discussed as stories
By considering the incident report as a story we donot consider it to be fiction. We do consider it as being some-
3.3. The affordance of a good story
thing told within a certain context and concerns and to be aexpert construction of information to suit the improvement of
We believe that all reporting schemes involve storytelling in
some way and that it is not adequate simply to have or recog-
The incident report, we have said in this paper, is only one
nise stories. Any inherent ‘storyness’ is not of interest, as Kelly
telling of the story that is told and retold. Reports are usually
et al. but rather the practices of storytelling: of
hand written (possibly in two systems), possibly then typed up,
building knowledge and making it repeatable and sharable. We
usually recounted and discussed in meetings, and sometimes
consider that schemes might afford a ‘good’ story for main-
re-told in the minutes of meetings. To look at how documents
taining and improving safety. The departmental scheme we
are understood and acted upon we must consider both their
say affords a good story because the mechanism and organi-
contents and manifestation here we look at con-
sation of the scheme suit and allow the processes of safety.
tents of a report and consider the different manifestations by
The paper forms allow anaesthetists to write reports, the
which the story is delivered (being pen and paper, network
arrangement of the form itself is in a way anaesthetists find
computer, PowerPoint, speech, etc). These different manifes-
useful, and the trust within anaesthetics departments allows
tations are directly related to the practical needs and activities
anaesthetists to write reports without fear of inappropriate
of maintaining and improving safety. Implied by storytelling
reprisals. The inter-departmental system was designed to
is that there is a teller of the story, and hopefully there is an
replicate these strengths in affording a good story, but failed to
audience to interpret it. We have then a simple framework by
persuade anaesthetists to afford it a story. In the worst cases,
which we can talk about the report as a story: content, mani-
the hospital wide systems did not afford such a good story:
festation, telling and interpreting.
the contents afforded by the forms was not seen as appropri-ate; the materials were not appropriate at some sites as they
3.2. The affordance of a story
required computer entry; anaesthetists were in most casesdiscouraged from writing reports because of the blame cul-
As a study of the practical undertaking of work rather than of
ture, and little perceived benefit; the interpretation of reports
isolated interactions with technology, incompatibilities with
was often not possible for anaesthetists who were not given
the findings from the field of Human Computer Interac-
access to them, and any interpretation by managers that did
tion are inevitable We use the term ‘affordance’ here,
as it is used in HCI, to allow discussion of how a designallows and encourages certain actions, but by taking a sys-tems view we are in some senses abusing the concept
We use the term affordance to describe how particular tech-nologies, working practices and organisational procedures are
Incident reporting schemes reflect and enable the practical
aligned to allow a story. We use it to understand how the
concerns of improving and maintaining safety, and can use-
soft and long-term problem of safety is addressed, and we
fully be seen as a way of telling stories. These stories must
say that technologies must both afford and be afforded a
be afforded by the scheme, and also be afforded by those
involved. We say that the structure of a report, plus the mate-
We cannot discuss the national scheme here, which we did
rials by which reports can be made and remade must afford a
not see in action, but we say the other three schemes all afford
(good) story. Anaesthetists, their managers, and the organisa-
a story. In the next section we consider whether they actually
tion at large, must likewise afford (good) stories to the scheme.
afford a ‘good’ story. The content of a report is afforded by
What counts as a good story is dependent upon the context of
an input form in each scheme. The departmental and inter-
its writing and use. We acknowledge that attempts in the NHS
departmental schemes placed an emphasis on free text. A
to collect and analyse incident information on a more coher-
story however need not be in free text, and we believe that
ent and widespread basis hold the potential to significantly
a story is also told in the hospital wide forms, although per-
increase safety; our argument is not against such attempts
haps not the story as the anaesthetist might wish to tell it.
but is to state that reporting at its basic level is not the collec-
The manifestations of reporting were paper, electronic and
tion of data but the telling and retelling of stories. Reporting
speech. Reports were afforded by placing paper forms in oper-
schemes at the departmental level in anaesthesia have been
ating theatres which were both useful and accessible, and then
successful and we believe the lessons from these should be
the electronic versions that were useful for distribution and
discussion were afforded by having someone type them up. Talk about reports was afforded by having meetings, or on theinter-departmental system by an online notice board. Inter-
Acknowledgements
preting of reports could be done by audit and risk managers byreading reports and others by attending meetings. The mech-
Prof. Ian Sommerville provided valuable contributions to this
anism does not determine the reporting scheme and we must
paper. We are very grateful to the anaesthetists involved in
consider that the scheme affords as well as is afforded a story.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
[13] M.J. O’Leary, Should reporting programmes talk to each
other? in: Proceedings of the Second Workshop on theInvestigation and Reporting of Incidents and Accidents
[1] E. Balka, M. Doyle-Waters, D. Lecznarowicz, J.M. FitzGerald,
(IRIA2003), Williamsburg, USA, 16–19 September, 2003, pp.
Technology and the role of patient safety: systems issues in
technology and patient safety, Int. J. Med. Inform. 76 (S1)
[14] M. Berg, Practices of reading and writing: the constitutive
role of the patient record in medical work Sociol. Health Illn.
[2] P. Barach, S.D. Small, Reporting and preventing medical
mishaps: lessons from non-medical near miss reporting
[15] J. Rooksby, S. Kay, Patient reports as stories of clinical work:
narrative and work in neuroradiology, Methods Inform. Med.
[3] T.G. Short, A. O’Regan, J.P. Jayasuriya, M. Rowbottom, T.A.
Buckley, T.E. Oh, Improvements in anaesthetic care resulting
[16] J. Seeley Brown, P. Duguid, The Social Life of Information,
from a critical incident reporting programme, Anaesthesia
Harvard Business School Press, Boston, 2000.
[17] J. Orr, Narratives at work: storytelling as cooperative
[4] C. Johnson, Failure in Safety Critical Systems: A Handbook of
diagnostic activity, in: Proceedings of the 1986 ACM
Incident Reporting, Glasgow University Press, Glasgow, 2003.
Conference on Computer-Supported Cooperative Work,
[5] NHS National Patient Safety Agency, Seven Steps to Patient
Austin, TX, 3–5 December, 1986, pp. 62–72.
Safety: A Guide for NHS Staff. Available at
[18] P.Z. Stavri, J.S. Ash, Does failure breed success: narrative
analysis of stories about computerised provider order entry,
Int. J. Med. Inform. 72 (2003) 9–13.
[6] B.A. Liang, A system of medical error disclosure, Qual. Saf.
[19] H. Karasti, K.S. Baker, G.C. Bowker, Ecological storytelling
and collaborative scientific activities, SIGGROUP Bull. 23 (2)
[7] P.Y. Bo ¨elle, P. Garnerin, J.F. Sicard, F. Clergue, F. Bonnet,
Voluntary reporting system in anaesthesia: is there a link
[20] K.M. Hunter, Doctors’ Stories: The Narrative Structure of
between undesirable and critical events? Qual. Health Care 9
Medical Knowledge, Princeton University Press, Princeton,
[8] N. Leveson, M. Daouk, N. Dulac, K. Marais, Applying STAMP
[21] T. Greenhalgh, Narrative and patient choice, in: A. Edwards,
in accident analysis, in: Proceedings of the Second
G. Elwyn (Eds.), Evidence Based Patient Choice, Oxford
Workshop on the Investigation and Reporting of Incidents
University Press, Oxford, 2001, pp. 206–219.
and Accidents (IRIA2003), Williamsburg, USA, 16–19
[22] R. Harper, Inside the IMF: An Ethnography of Documents,
Technology and Organisational Action, Academic Press, San
[9] J. Rooksby, R.M. Gerry, A.F. Smith, Sharing lessons learned:
an online incident reporting scheme for anaesthesia, in:
[23] R.H.R. Harper, K.P.A. O’Hara, A.J. Sellen, D.J.R. Duthie,
Proceedings of Current Perspectives in Healthcare
Towards the paperless hospital? Br. J. Anaesth. 78 (1997)
Computing Conference (HC2004), Harrogate UK, 22–24
[24] G. Fitzpatrick, Integrated care and the working record,
[10] A.F. Smith, D. Goodwin, M. Mort, A. Pope, Expertise in
Health Inform. J. 10 (4) (2004) 291–302.
practice: an ethnographic study exploring acquisition and
[25] A. Crabtree, Designing Collaborative Systems: A Practical
use of knowledge in anaesthesia, Br. J. Anaesth. 91 (3) (2003)
Guide to Ethnography, Spinger-Verlag, London, 2003.
[26] H.R. Hartson, Cognitive, physical, sensory and functional
[11] M. Mort, D. Goodwin, C. Pope, A.F. Smith, Take-off and
affordances in interaction design, Behav. Inf. Technol. 22 (5)
landing in anaesthesia: negotiating the human machine
collective, paper presented at the Society for the Social
[27] S. Kelly, M. Iszatt White, D. Randall, M. Rouncefield, Stories
Studies of Science (4S) Milwaukee, USA, November 2002.
of educational leadership, in: Paper Presented at Educational
[12] M. Mort, D. Goodwin, A.F. Smith, C. Pope, Safe asleep?
Leadership in Pluralistic Societies (CCEAM 2004), Hong Kong
Human machine relations in medical practice, Soc. Sci. Med.
American Journal of Hematology 82:349–356 (2007)The Effect of Budesonide Mouthwash on Oral ChronicIsmail Sari,1* Fevzi Altuntas,1 I˙smail Kocyigit,2 Yildiray Sisman,3 Bulent Eser,1 Aydin Unal,2Turgay Fen,4 Ayten Ferahbas,5 Ahmet Ozturk,6 Ali Unal,1 and Mustafa Cetin11 Department of Hematology, Faculty of Medicine, M.K. Dedeman Oncology Hospital, Erciyes University,Cappadoccia Transplant Ce
Mission Team Members, Honduras has been an independent nation since it declared independence from Spain in 1821. It is one of the poorest Central American nations, with unemployment at about 25%. Some of the larger cities have become modern while many rural areas have no infrastructure. Medically, The fertility rate is approximately 3.7 per woman. The under-five mortality rate is at 40 per 1
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 S ( 2 0 0 7 ) S205–S211
j o u r n a l h o m e p a g e : w w w . i n t l . e l s e v i e r h e a l t h . c o m / j o u r n a l s / i j m i
Incident reporting schemes and the need for a good story