Page 12 - ANZCP Gazette NOVEMBER 2022

PIRS-2 REPORT
Tim Wilcox CCP, Life Member ANZCP - PIRS-2 Editor
Tena koutou katoa — ‘Hello everyone’
PIRS-2 continues to receive sporadic reports that generate positive feedback to the PIRS team. However, despite the universally reported value of the PIRS reports from report recipients, the infrequency of submissions demonstrates continued underreporting. The quality of reports has been enhanced by photos and video uploaded with the report form (upload links are at the bottom of the submission form). Given the ease of capturing components of incidents using smart phones, we strongly recommend taking photos or a short video to better illustrate aspects of the reports.
The ANZCP Perfusion Improvement Reporting System continues to attract interest internationally with correspondence from readers of the PIRS reports and - as signalled in the last issue of the Gazette - PIRS has now been integrated onto the Netherlands Society of Extracorporeal Circulation website as their vehicle for sharing good catch incidents. Like the Canadian Society, the NeSECC website has a link to the PIRS reporting form. To explain the background and purposes of the PIRS, NeSECC recently hosted a webinar for their members, that was well received.
Similarly AMSECT is in discussions with Orrum Analytics PSO, who have established an on-line incident reporting system for perfusionists. Orrum are using the ANZCP PIRS submission form with the permission of the ANZCP Executive.
We have seen requests for pirs@anzcp.org to be added to the PIRS-2 email list grow more recently as a result of the NeSECC initiative, with reports going out to approximately 250 recipients.
Given the perceived value in these reports – bearing in mind only deidentified summaries of those reports with permission to publish are placed on the PIRS website and emailed to the PIRS email list – how do we encourage perfusionist to report good catch incidents where expertise and experience have averted further harm?
A major driver to voluntary reporting is culture. Fostering a no blame culture in the context of perfusion starts with sharing good catch near-miss and good catch no-harm incidents with the immediate perfusion team – such as a team meeting – where the incident is discussed freely. We know from surveys that this happens in a high percentage of centres. It is therefore a just short step to filling out a PIRS report on a device – be that desktop or smart phone. The link is easily downloaded: https://anzcp.org/pirs-ii/ .
Leadership is paramount in fostering reporting good catch near-miss and good catch no-harm incidents. The PIRS team plans to contact chief perfusionists to seek their support in re energising their teams to share good catch near-miss and good catch no-harm incidents through the ANZCP PIRS. Your smart actions managing what you might consider a minor incident might prevent a major incident occurring.
9 NOVEMBER 2022 | www.anzcp.org