Incident reporting and analysis is a key tool in the promotion of patient safety. However, there are many limiting factors. For such systems to be effective, staff must report incidents in the first place and there must be feedback and learning if mistakes are not to be repeated.

Drs Jon Arnot-Smith and Chris Cassidy are working on this area, in conjunction with Professor Smith. We are working with the UK National Patient Safety Agency on this programme. The Agency has provided us with data from the National Reporting and Learning System (NRLS), and we are pursuing two lines of enquiry. First, we are making an assessment of the material contained in the database and the way incidents are classified and coded.

Second, we are extracting data of relevance to anaesthetic practice and taking responsibility for feeding this back into professional networks. We are starting to examine the learning on aspects such as equipment failure, problems with the patient’s airway, regional anaesthesia and the use of medicines for neuromuscular blockade.

Finally, we are performing a comparative epidemiological mapping of incident reporting through various mechanisms, to establish the relative importance of ‘educational’ discussion of problems within anaesthetic departments compared with formal reporting through Trust-based schemes and the NRLS.