Piloting of mrf2 Aim to test and comment on quality of form


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Piloting of MRF2









Non traditional research techniques



“(...) This study was one of a few pivotal events responsible for the dramatic success in promoting anesthesia patient safety (...)”

  • “(...) This study was one of a few pivotal events responsible for the dramatic success in promoting anesthesia patient safety (...)”

  • Pierce EC. Looking back on the anesthesia critical incident studies and their role in catalysing patient safety. Qual Saf Health Care 2002;11:282-3.



Communication and analysis of critical incident system

  • Fundación Hospital Alcorcón 1999.

  • CQI

  • Anonymous communication and voluntary of critical incidents.

  • Root analysis.

  • Improvement actions.

  • Does not need negative publicity



Results 1999-2003

  • 44311 anesthetic procedures

  • 446 critical incidents (1 %)



New protocols (6)

  • New protocols (6)

  • Modification of previous protocols (2)

  • IC Modification (1)

  • Hazardous material discharge (4)

  • New material (4)

  • equipment repair (2)

  • equipment modification (3)

  • Sessions (16)

  • Alerts (13)





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