Évaluation d'un système informatisé de signalement volontaire et anonyme d'événements indésirables dans un CHU

To evaluate the impact of an adverse event reporting system (Computer Adverse Event Reporting System: CAERS), anonymously accessible to all anesthesia and surgical intensive care medicine department staff members in a large tertiary university hospital. All consecutive adverse events (AE) reported from January 2013 and December 2013 were retrospectively analyzed. The number of report, the type of reporting personal and the severity of the reported adverse events were analyzed. Two hundred and twenty-two AE were recorded on CAERS. Physicians reported 25% AE. These AE concerned 0.7% of the anesthetic activity and 6.4 per 1000 patient days in the surgical intensive care unit. Among AE, 3 were serious adverse events, 19 were near misses, and 200 were incidents. Almost of 80% of incidents were reported by non-medical staff. Only the serious adverse events and the near misses led to corrective action. The easily accessible by all staff CAERS has enabled serious adverse events reporting and near misses mainly related to a lack of equipment or organizational problems. Systemic analysis of the AE was followed by corrective measures. Nevertheless, medical and non-medical staff is still reluctant to systematically use this system to report serious adverse events related to medical malpractice.