Introduction
Despite efforts to improve airway management, little is known about detecting structural weaknesses in anaesthesia departments(1)

The anonymous reporting of near-misses to a departmental Critical Incident Reporting System (CIRS) is one starting point to identify and address these possible weaknesses, hereby improving quality

This study investigates which aspects motivate or impede anaesthesia providers to report near-misses as critical incidents to a departmental CIRS

Methods
Step1: Documentation of all elective and emergency airway management procedures and major and minor airway events over a period of two months

Step 2: Screening of these events to identify potential critical incidents that would qualify to be reported to the departmental CIRS

Step 3:Semi-structured interviews with responsible and involved anaesthesia providers to clarify the reasons for reporting or not reporting critical incidents. The interviews were analysed with the framework method(2)

Results
574 airway events in 3670 airway management cases (15.6%) were documented in two months

102 critical incidents out of the 574 events met the criteria for reporting to the CIRS (17.8%)

Out of 102 critical incidents only 1 was reported to the departmental CIRS (<1%)

Analysis of the interviews showed:

Different conceptions about the aim of CIRS; different conceptions were for example “learn from mistakes”, “uncovering systemic failures”, “eliminating potential sources of mistakes”, “sensitize others to a problem”, and "improvement of processes”

Lack of feedback; there was a wish for more feedback, for example more feedback sessions where CIRS cases are discussed or a regular e-mail from the CIRS group with findings from the reports

When asked about criteria for a critical incident, individual mistakes were often exclusively mentioned. Providers only reported critical events when they felt that the reporting could prevent future incidents or illustrate a learning point. Other criteria were that a patient was in danger or that something did not go as planned

It was repeatedly unclear who should report a critical incident within a team

Conclusions
Screening all airway events showed significant underreporting of critical incidents to the CIRS

If people only report when a mistake is made, and they at the same time require that others can learn from the report, then this introduces a high reporting threshold for critical incidents

We identified a need to improve the feedback from the CIRS group to highlight its benefits for the anaesthesia providers, and also a need to make the criteria for reporting critical incidents more clear to the anaesthesia providers  

The CIRS may contribute to identifying possible structural weaknesses, but if reporting to the CIRS does not embrace all relevant cases, very little can be learned from these events to improve health care and patient safety

A qualitative study on reporting of critical airway incidents to a critical incident reporting system: reasons for underreporting