title: Patient safety event reporting in critical care: a study of three intensive care units.
abstract: OBJECTIVE
  To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs.
  
  
  METHODS
  Prospective, single-center, interventional study.
  
  
  METHODS
  A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital.
  
  
  METHODS
  Adult patients admitted to these three study ICUs.
  
  
  METHODS
  Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns.
  
  
  RESULTS
  During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p < .001).
  
  
  CONCLUSIONS
  This card-based reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal important preferences and priorities for reporting medical errors and patient safety events.
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Carolyn B
authors.initials: CB
authors.lastname: Harris
authors.forename: Melissa J
authors.initials: MJ
authors.lastname: Krauss
authors.forename: Craig M
authors.initials: CM
authors.lastname: Coopersmith
authors.forename: Michael
authors.initials: M
authors.lastname: Avidan
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Nast
authors.forename: Marin H
authors.initials: MH
authors.lastname: Kollef
authors.forename: W Claiborne
authors.initials: WC
authors.lastname: Dunagan
authors.forename: Victoria J
authors.initials: VJ
authors.lastname: Fraser
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D004282:Documentation / Q000379:methods*; D006739:Hospital Administration; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D019300:Medical Errors; D019982:Organizational Case Studies; D010564:Personnel, Hospital; D011446:Prospective Studies; D012308:Risk Management / Q000379:methods*; D012449:Safety