Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia.

Sharma, S. and Smith, A. F. and Rooksby, J. and Gerry, B. (2006) Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia. Anaesthesia, 61 (4). pp. 350-354. ISSN 1365-2044

Full text not available from this repository.


In this qualitative study using observation and interviews, 10 anaesthetists from five Departments of Anaesthesia in the North-West region of England were enlisted to participate in the design of an online system to allow the sharing of critical incidents. Respondents perceived that existing schemes had differing and sometimes conflicting aims. Reporting was used for reasons other than simply logging incidents in the interests of promoting patient safety. No existing scheme allowed the lessons learned from incidents to be shared between members of the professional group from which they arose. Using participants' suggestions, we designed a simple, secure, anonymous system favouring free-text description, intended to enable the on-line sharing and discussion of selected incidents. Seven incidents were posted during the 6-month pilot period. The practitioners in our study valued the opportunity to share and discuss educational incidents ‘horizontally’ within their community of practice. We suggest that large-scale reporting systems either incorporate such a function or allow other systems that permit such sharing to co-exist.

Item Type:
Journal Article
Journal or Publication Title:
Additional Information:
Incident reports are crucial to the maintenance and improvement of patient safety. We investigated reporting practices in the Anaesthesia departments of six NHS Trusts. We discovered that reports were not shared between Trusts and that there would be value in this. Using a synthesis of participatory design and ethnography, we developed a prototype that afforded ease of use, peer learning and addressed trust and privacy concerns. Successful trialling took place over six months, results were presented to the Royal College of Anaesthetists. This paper is co-authored with two NHS staff, and published in Anaesthesia, a high impact journal (factor 2.427). RAE_import_type : Journal article RAE_uoa_type : Computer Science and Informatics
Uncontrolled Keywords:
ID Code:
Deposited By:
Deposited On:
28 Mar 2008 15:16
Last Modified:
20 Sep 2023 00:01