Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study.
OBJECTIVE
The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action.


METHODS
A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required.


RESULTS
During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards.


CONCLUSIONS
After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.
Department of Medicine, Queen's University, Kingston General Hospital, Kingston, ON, Canada K7L 3N6. ilanr@kgh.kari.net
Roy
R
Ilan
Mae
M
Squires
Christina
C
Panopoulos
Andrew
A
Day
D016009:Chi-Square Distribution; D004282:Documentation / Q000379:methods*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D016015:Logistic Models; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D061214:Patient Safety; D011446:Prospective Studies; D012308:Risk Management / Q000379:methods*