Intended for healthcare professionals


Electronic incident reporting and professional monitoring transforms culture

BMJ 2004; 329 doi: (Published 01 July 2004) Cite this as: BMJ 2004;329:51
  1. Stephen Bolsin, director, Division of Perioperative Medicine, Anaesthesia and Pain Management (steveb{at},
  2. Andrew Patrick, staff specialist,
  3. Bernie Creati, staff specialist,
  4. Mark Colson, staff specialist,
  5. Leah Freestone, provisional fellow
  1. Geelong Hospital, Geelong, VIC 3220, Australia

    EDITOR—We report how incident reporting and personal professional monitoring has been achieved using programmed handheld computing devices (personal digital assistants (PDAs)). Data and performance information have been collected and critical incidents reported for accredited trainees of the Australian and New Zealand College of Anaesthetists (ANZCA) in Geelong.1 2 This work favourably transforms the culture of the users, which has been our goal for some time.3 4

    The programmed PDA has allowed a denominator figure to be supplied for cases undertaken by the trainees, as well as an assessment of the impact on patient outcome. Thus incidents reported by trainees occurred in 1.5% of anaesthetics, but half of the incidents reported had no impact or a minor impact on patient outcomes.1 This may well be the “near miss” incident data that are the “holy grail” of healthcare safety experts. Our most recent (unpublished) study has found that 98% of all incidents occurring in the practice of ANZCA accredited trainees are reported using this programmed PDA technology.

    All incidents are routinely emailed to the quality coordinator for the Division of Perioperative Medicine, Anaesthesia, and Pain Management for analysis and system improvement when possible. Critical incidents in which the outcome for the patient was judged severe or causing death are automatically emailed to the quality manager for Geelong Hospital. We are planning research to assess the effect of these automated critical incident alerts on critical incident rates over time.

    The information in the database is collected under an approved quality assurance programme and therefore in the State of Victoria is protected from legal disclosure. The Victorian privacy legislation may allow patients to access data on their particular case but would not allow open disclosure of all the information in the database.


    • Competing interests SB, AP, and MC designed and developed the PDA programme described.


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