Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.
OBJECTIVE
The objective was to evaluate a new mechanism for reporting and classifying patient safety events to increase reporting and identify patient safety priorities.


METHODS
A voluntary patient safety event reporting system accessible by all health care workers was implemented in the Cardiothoracic Intensive Care and Post Anesthesia Care Units. Information collected included patient identifiers; date, time, and location of report and event; type and description of event; and severity score. Narrative descriptions of events were analyzed and coded to describe when in the care process the event occurred, what occurred, and a causal classification of why the event occurred.


RESULTS
A total of 163 reports describing 157 events were received. These included 121 events reported from the intensive care unit (25.3 reported events per 1000 patient-days), a 3-fold increase compared with the preexisting on-line reporting system. A total of 113 reports (69%) came from nurses, 31 from physicians (19%), and 10 from other staff (6%). A majority of events (85, 54%) reached the patient but caused no harm. Multiple causes were identified for the majority of events. The most frequent causes were related to human factors (48%) and organizational factors (34%).


CONCLUSIONS
Health care workers were willing to use the patient safety event reporting system, which yielded a broad range of patient safety data. Patient safety events are multifaceted and often have multiple causal factors. Application of a causal classification model for patient safety event coding in the intensive care and preoperative and postoperative care units is feasible and facilitates local communication of important event-related information.
Nast
Patricia A
PA
Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO 63110, USA. pnast@im.wustl.edu
Avidan
Michael
M
Harris
Carolyn B
CB
Krauss
Melissa J
MJ
Jacobsohn
Eric
E
Petlin
Ann
A
Dunagan
W Claiborne
WC
Fraser
Victoria J
VJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000145:classification / Q000628:therapy*; D013504:Cardiovascular Surgical Procedures / Q000009:adverse effects; D005260:Female; D005568:Forms and Records Control; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D019300:Medical Errors / Q000145:classification* / Q000517:prevention & control; D008875:Middle Aged; D008923:Missouri; D010355:Patient Identification Systems; D011182:Postoperative Care / Q000592:standards*; D011183:Postoperative Complications / Q000145:classification / Q000209:etiology / Q000517:prevention & control; D012308:Risk Management / Q000379:methods* / Q000706:statistics & numerical data; D017751:Safety Management; D012720:Severity of Illness Index