ICU incident reporting systems,☆☆

https://doi.org/10.1053/jcrc.2002.35100Get rights and content

Abstract

Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other high-risk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent.We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Health-care Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Re-search and Quality. Copyright 2002, Elsevier Science (USA). All rights reserved.

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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  • Cited by (0)

    Supported in part by an Agency for Healthcare Research and Quality grant (#U18HS11902-01).

    ☆☆

    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].

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