title: Learning from defects using a comprehensive management system for incident reports in critical care.
abstract: Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.
authors.affiliation: College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
authors.forename: Y M
authors.initials: YM
authors.lastname: Arabi
authors.affiliation: Quality Management Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: S M
authors.initials: SM
authors.lastname: Al Owais
authors.affiliation: Anesthesia Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: K
authors.initials: K
authors.lastname: Al-Attas
authors.affiliation: College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: A
authors.initials: A
authors.lastname: Alamry
authors.affiliation: Quality Management Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: K
authors.initials: K
authors.lastname: AlZahrani
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: B
authors.initials: B
authors.lastname: Baig
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: D
authors.initials: D
authors.lastname: White
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: A M
authors.initials: AM
authors.lastname: Deeb
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: H D
authors.initials: HD
authors.lastname: Al-Dozri
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: S
authors.initials: S
authors.lastname: Haddad
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: H M
authors.initials: HM
authors.lastname: Tamim
authors.affiliation: King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: S
authors.initials: S
authors.lastname: Taher
mesh_terms: D003422:Critical Care; D006801:Humans; D007857:Leadership; D061214:Patient Safety; D012308:Risk Management
keywords: Intensive Care Department; Saudi Arabia; administration; critical care; culture; healthcare; hospital information systems; incident report; medical errors; quality assurance; quality control; safety culture; systems analysis; voluntary programs