Original scientific article
A New Safety Event Reporting System Improves Physician Reporting in the Surgical Intensive Care Unit

https://doi.org/10.1016/j.jamcollsurg.2006.02.035Get rights and content

Background

Medical errors are common, and physicians have notably been poor medical error reporters. In the SICU, reporting was generally poor and reporting by physicians was virtually nonexistent. This study was designed to observe changes in error reporting in an SICU when a new card-based system (SAFE) was introduced.

Study design

Before implementation of the SAFE reporting system, education was given to all SICU healthcare providers. The SAFE system was introduced into the SICU for a 9-month period from March 2003 through November 2003, to replace an underused online system. Data were collected from the SAFE card reports and the online reporting systems during introduction, removal, and reimplementation of these cards. Reporting rates were calculated as number of reported events per 1,000 patient days.

Results

Reporting rates increased from 19 to 51 reports per 1,000 patient days after the SAFE cards were introduced into the ICU (p   0.001). Physician reporting increased most, rising from 0.3 to 5.8 reports per 1,000 patient days; nursing reporting also increased from 18 to 39 reports per 1,000 patient days (both p  0.001). When the SAFE cards were removed, physician reporting declined to 0 reports per 1,000 patient days (p = 0.01) and rose to 8.1 (p = 0.001) when the cards were returned, similar to nursing results. A higher proportion of physician reports were events that caused harm compared with no effect (p < 0.05).

Conclusions

A card reporting system, combined with appropriate education, improved overall reporting in the SICU, especially among physician providers. Nurses were more likely to use reporting systems than were physicians. Physician reports were more likely to be of events that caused harm.

Section snippets

Study location and setting

The SICU is a 24-bed, semiclosed unit providing critical care services for diverse adult general surgical patients, including vascular, transplant, colorectal, burn, and trauma patients.

Study design and implementation

A complete description of the study design and reporting methods was previously published by Osmon and colleagues.8 Planning meetings were held with key SICU personnel, and the proposed study was presented to the multidisciplinary Quality Improvement (QI) committee. Group and individual in-services about the

Introduction of the SAFE cards

In the year before SAFE card introduction (January to December 2002), there were 117 SICU reports submitted to the online adverse event reporting system, yielding 19 reports per 1,000 patient days. A total of 241 SAFE card reports were received over the 9-month study period in the SICU. One report was excluded because it related to staff safety rather than patient safety. The remaining 240 reports were analyzed. These reports described 230 unique events because some events generated multiple

Discussion

The most significant improvement was among physician reporters, with nearly a 19-fold increase in reporting using the SAFE card system. There are likely several factors that contributed to this increase. Prestudy focus groups found that physicians expressed no motivation to report events other than from a legal perspective to risk management. The focus groups found that physicians believed that reporting did not lead to improved care nor did it solve the root of the problem, and that there was

Acknowledgment

We acknowledge the SICU medical and nursing staff, and members of the QI and OSC for their time and assistance with this project.

References (18)

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Competing Interests Declared: None.

This project was supported by a grant from the Agency for Healthcare Research and Quality, #HS11898-1.

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