ICU incident reporting systems☆,☆☆
Section snippets
Reporting systems: A strategy for learning from errors
The 1999 report from the Institute of Medicine16 emphasized reporting systems as a key strategy for learning from errors and preventing their recur-rence. The report emphasized a potential conflict inherent in the goals of the system: “Reporting systems have the potential to serve two important functions. They can hold providers accountable for performance, or, alternatively, they can provide information that leads to improved safety. eral-Conceptually, these purposes are not incompatible, but
Incident reporting and monitoring in medicine
Traditional reporting of adverse events in U.S. hospitals has severely underestimated the true rate of problems in part owing to clinicians' reluctance to report. In a study of patients admitted over a 6-month period to 5 patient care units (a medical ICU, 2 surgical ICUs, and 2 medical general care units) in a tertiary care hospital, of 54 adverse drug events identified, only 3 had a corresponding incident report submitted to the hospital's quality assurance program or had generated a call on
Incident reporting and monitoring in the ICU
The incident monitoring approach used in these settings has often sought causative factors related to the occurrence of human error, including communication, equipment design—particularly inter-faces with patients and staff—and environmental and management influence. This strategy has been found to provide useful information not readily available from other sources such as chart reviews or observational studies. Led by efforts from the AIMS-ICU, related investigators have also developed and
Participants
Through the Society of Critical Care Medicine (SCCM), we have recruited 30 adult or pediatric ICUs in geographically diverse hospitals that are willing to take an active part in reporting and seeking to reduce incidents and errors. Each participating ICU has designated an ICU physician as the principal investigator (PI) and an ICU nurse as the co-PI. Institutional participation is secured with the institution's chief medical officer and hospital risk management department. For the purposes of
The ICUSRS reporting form
The reporting form is partly based on the paper-based generic Incident Form in use in the latest version of the AIMS-2. This Web-based form elicits a narrative description of the incident, contextual information about the patient and staff, predisposing and limiting factors, queries about specific system factors, and what measures could be taken to prevent similar incidents in the future. For each of these areas, prompts help to facilitate responses that are sufficiently detailed to provide
The ICUSRS reporting process
All staff members will be encouraged to report incidents, especially near misses, on the ICUSRS Web site. To facilitate reporting by nurses and other staff, the Web-based version of the system will be available at all bedside PCs, as well as PCs in the central nursing station and conference room.
The project will emphasize to staff that anonymity is a key requirement for good, ongoing reporting. Thus, in the reports, neither staff member nor patients are identified. Each hospital will receive a
Analysis of reports
Reports generated by the ICUSRS will be assembled and reviewed by the core research team. Although most efforts to report, investigate, and address errors in medicine have focused on individual provider behaviors, the experience of other industries suggests that greater opportunity for understanding and improvement may be found by focusing on the system characteristics of work settings and health care organizations. Our initial analysis will be largely descriptive, using the ICU as the unit of
Feedback to ICUs
The primary audience for data from this reporting system is ICU providers including physicians, nurses, pharmacists, and respiratory therapists, as well as hospital risk managers. Quarterly reports will be returned to each unit regarding frequency of errors and system failures contributing to errors. Reports will be tailored to contain summary information on the incidents each unit has submitted to the database with comparisons to the totals for all reporting ICUs. Reports will be sent in
Summary
The risk of error for patients in ICUs will not abate spontaneously. In fact, in the United States, the aging population and increased burden of chronic disease, combined with a projected shortage of intensivists and nurses, are likely to increase pressures on ICU services, with a concomitant increase in the risk for errors. The aging of the U.S. population is predicted to result in a shortfall of 35% in the supply of critical care specialists by the year 2030. Anesthesia and intensive care
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Supported in part by an Agency for Healthcare Research and Quality grant (#U18HS11902-01).
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Address reprint requests to Albert W. Wu, MD, MPH, Health Services Research and Development Center, 624 N Broadway, Room 633, Baltimore, MD 21205. E-mail: [email protected].