Development of the ICU Safety Reporting System

The Intensive Care Unit Safety Reporting System (ICUSRS) is a voluntary web-based reporting system to improve patient safety in intensive care units (ICUs). ICUSRS was designed to be non-punitive and confidential, employ expert analysis, provide timely analysis and feedback, and be systems oriented, democratic, low-burden, web-based, simple, and sustainable. Important considerations included coordination with other reporting systems, and concerns about confidentiality and liability. In the first year, 18 U.S. ICUs (2 pediatric and 16 adult) participated; 50% were academic medical centers, 44% community teaching hospitals, and 6% community hospitals. Adult ICUs were 13% surgical, 19% medical, 13% cardiac surgical, 13% mixed medical/surgical, and 24% other. ICUSRS was constructed for Windows. Reporting is anonymous to both patient and reporter. The form begins with a verbatim account of the incident, followed by close-ended questions about factors that might have contributed to, minimized, and prevented similar incidents. Outcomes include death, physical injury, discomfort, dissatisfaction, and economic outcomes. Reporters can review and edit incidents before submitting. After submission, reports are stripped of identifiers, analyzed by ICU safety experts, and fed back to each site. In the first month of participation, sites averaged 4.8 reports. Mean reporting peaked at 7.5 in month 11 and was 4.3 in month 12. There was wide variability in reporting among sites. Half of the reports described near misses. The ICUSRS incorporates features of an effective reporting system and could be used by front line health care providers.

[1]  R. Hicks,et al.  Medication Errors: Experience of the United States Pharmacopeia (USP) MEDMARX Reporting System , 2003, Journal of clinical pharmacology.

[2]  C. Vincent.  Understanding and responding to adverse events. , 2003, The New England journal of medicine.

[3]  L. Leape.  Reporting of adverse events. , 2002, The New England journal of medicine.

[4]  K. Nelson,et al.  Developing a comprehensive electronic adverse event reporting system in an academic health center. , 2002, The Joint Commission journal on quality improvement.

[5]  W B Runciman,et al.  ORGANISATIONAL MATTERS: NATIONAL INITIATIVES Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system—is this the right model? , 2002 .

[6]  Albert W Wu,et al.  ICU incident reporting systems. , 2002, Journal of critical care.

[7]  Todd Dorman,et al.  Building safety into ICU care. , 2002, Journal of critical care.

[8]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[9]  R. Gaynes,et al.  Feeding back surveillance data to prevent hospital-acquired infections. , 2001, Emerging infectious diseases.

[10]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .

[11]  J. Sexton,et al.  Error, stress, and teamwork in medicine and aviation: cross sectional surveys , 2000, BMJ : British Medical Journal.

[12]  N. Stanhope,et al.  Reasons for not reporting adverse incidents: an empirical study. , 1999, Journal of evaluation in clinical practice.

[13]  C. Vincent,et al.  Framework for analysing risk and safety in clinical medicine. , 1998, BMJ.

[14]  H S Kaplan,et al.  The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. , 1998, Archives of pathology & laboratory medicine.

[15]  D. Cousins,et al.  Developing a uniform reporting system for preventable adverse drug events. , 1998, Clinical therapeutics.

[16]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[17]  L. Andrews,et al.  An alternative strategy for studying adverse events in medical care , 1997, The Lancet.

[18]  Leiyu Shi,et al.  Health Services Research Methods , 1996 .

[19]  U. Beckmann,et al.  The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An Analysis of the First Year of Reporting , 1996, Anaesthesia and intensive care.

[20]  U. Beckmann,et al.  The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. the Development and Evaluation of an Incident Reporting System in Intensive Care , 1996, Anaesthesia and intensive care.

[21]  Y. Donchin,et al.  A look into the nature and causes of human errors in the intensive care unit , 2022 .

[22]  R. Holland,et al.  System Failure: An Analysis of 2000 Incident Reports , 1993 .

[23]  A. Sellen,et al.  Human Failure: An Analysis of 2000 Incident Reports , 1993, Anaesthesia and intensive care.