Original scientific articleA New Safety Event Reporting System Improves Physician Reporting in the Surgical Intensive Care Unit
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.
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2015, Clinics in Chest MedicineCitation Excerpt :Historically, physician participation in voluntary event reporting has been low for a variety of reasons. It has been shown that there is a fear of litigation, disciplinary action, and fear of loss of reputation.36 Other reasons for the lack of reporting include the voluntary nature of reporting, lack of agreement on a standardized definition of a reportable event, perceived lack of benefit, apathy, lack of feedback, time constraints, and unfamiliarity with the process.37,38
Does error and adverse event reporting by physicians and nurses differ?
2008, Joint Commission Journal on Quality and Patient SafetyCitation Excerpt :We found that as the impact level of a report increased, so did the percentage of physician reports. The finding that physicians reported events that caused serious harm to patients at a rate that was three times higher than their average reporting rate is consistent with the finding that physicians are more likely to report if an event caused harm.10 Yet, physician reports still accounted for only 3.5% of total reports at these higher impact levels.
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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.