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Reporting adverse events (AEs) is integral to patient safety [1]. AEs are reported at the Royal Infirmary of Edinburgh (RIE) using the DATIX platform. There are concerns about under-reporting of AEs from the operating theatre (OT) environment and implications for patient safety [2]. A previous one-day pilot study in December 2018 found a discrepancy between actual and reported numbers of AEs. To inform quality improvement, we wanted to investigate the reasons for not reporting AEs and to quantify AEs over 5 consecutive days.
Surveys were distributed to anaesthetists and theatre staff in April 2019 to evaluate AE reporting. The AE occurrence audit took place on 5 consecutive days between 0800 and 1700 in the 24 OTs in February 2020, consisting of 94 theatre days. Theatre staff were encouraged to record AEs or any unexpected, untoward, unsafe, concerning or surprising events with a daily questionnaire. This was compared with formal DATIX reports from the same period. This project was registered with the local QIT chair.
The survey on barriers to reporting was completed by 65 anaesthetists and 59 theatre staff. Sixty-one (49%) reported no previous training in AE reporting. Fifty-seven (46%) had not reported AEs which occurred and 28 (23%) were unsure. Common barriers included time needed to complete a report (n=32, 26%) and lack of feedback (n=23, 19%).
In the audit, 29 AEs were reported in total from 26 (28%) theatre sessions. Forty-one (45%) theatre sessions reported no AEs and 27 (29%) did not return the questionnaire. The response rate was 71%. There was a median of 5 (IQR±3 [range 4-9]) AEs per day across all OTs. There was only 1 formal DATIX report in this period. The categories of AEs are shown in the table.
| Type of event | Reported through audit | Reported by DATIX |
| Devices & equipment | 8 | 0 |
| Anaesthetic issues | 7 | 1 |
| Delays/cancellations | 6 | 0 |
| Information technology | 2 | 0 |
| Other | 2 | 0 |
| Medication errors | 1 | 0 |
| Removal of lines | 1 | 0 |
| Clinical sharps | 1 | 0 |
| Transfer | 1 | 0 |
| Total | 29 | 1 |
This project demonstrates significant under-reporting of AEs in the OT environment, consistent with other healthcare settings [2]. AEs were most commonly related to devices and equipment, in concordance with other research [1]. Our survey suggests that appropriate reporting of AEs will be promoted by planned streamlining of the reporting process, education, feedback and promotion of a ‘just culture’ [1].
