Patient safety event reporting in critical care: a study of three intensive care units.
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.
Harris
Carolyn B
CB
Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
Krauss
Melissa J
MJ
Coopersmith
Craig M
CM
Avidan
Michael
M
Nast
Patricia A
PA
Kollef
Marin H
MH
Dunagan
W Claiborne
WC
Fraser
Victoria J
VJ
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