• Johannes Köbberling.
• Zentrum für Innere Medizin, Kliniken St. Antonius, Lehrstuhl Innere Medizin II der Universität Witten/Herdecke, Wuppertal. Koebberling@antonius.de
• Med Klin. 2005 Mar 15;100(3):143-8.

AbstractIt may be seen as regrettable that a measure which is suitable for improvement of quality in medicine is broadly discussed only in the context of risk avoidance. The system of reporting adverse events (incidents), known under its internationally used term CIRS, is based on the observation that there is a close correlation between the occurrence of severe incidents with consequences and milder incidents or near misses without consequences. By avoiding mild incidents the severe incidents will automatical also be reduced. In contrast to a classic analysis of mistakes and errors the consequence itself only plays a minor role with CIRS. In Germany mistakes are usually seen under the aspects of a personal responsibility and they are prone to sanctions. But only when mistakes are accepted as occurring everywhere and with everybody and when they are regarded under the aspect of how to be avoided in future the necessary transparency can grow and an open dealing with mistakes can arise. This enables analyses with the only goal of quality improvement by avoidance of mistakes.

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