Toward learning from patient safety reporting systems.
OBJECTIVE
To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety.


METHODS
Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm.


RESULTS
Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm.


CONCLUSIONS
The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.
Pronovost
Peter J
PJ
Department of Anesthesiology & Critical Care Medicine, Quality & Safety Research Group, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. ppronovo@jhmi.edu
Thompson
David A
DA
Holzmueller
Christine G
CG
Lubomski
Lisa H
LH
Dorman
Todd
T
Dickman
Fern
F
Fahey
Maureen
M
Steinwachs
Donald M
DM
Engineer
Lilly
L
Sexton
J Bryan
JB
Wu
Albert W
AW
Morlock
Laura L
LL
D000328:Adult; D002648:Child; D015331:Cohort Studies; D006801:Humans; D007373:Interinstitutional Relations; D020407:Internet; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D009862:Online Systems; D011446:Prospective Studies; D012307:Risk Factors; D012308:Risk Management; D014481:United States