Elsevier

Journal of Critical Care

Volume 21, Issue 4, December 2006, Pages 305-315
Journal of Critical Care

Health Services Research
Toward learning from patient safety reporting systems

https://doi.org/10.1016/j.jcrc.2006.07.001Get rights and content

Abstract

Purpose

To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety.

Materials and Methods

Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm.

Results

Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm.

Conclusions

The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Introduction

Tens of thousands of people are harmed rather than helped by medical care every year [1], [2], [3]. In response, the US Congress allocated more than $50 million for patient safety research [4]. The Agency for Healthcare Research and Quality invested some of this money in 16 demonstration projects for patient safety reporting systems (PSRSs) (Marge Keyes, AHRQ, personal communication, 5/10/2005). In addition, Congress passed a bill (HR 663 and S 720) [5] to “improve patient safety and reduce the incidence of events that adversely affect patient safety” [6].

Patient safety reporting systems that identify risks to patients can be used to improve patient safety [2], [7]. Indeed, other high-risk industries, such as commercial aviation, have used reporting systems to improve safety [8]. When an incident occurs in health care, organizations must understand what happened and why, how to reduce the probability of recurrence, and how they know their interventions were effective [9], [10]. Patient safety reporting systems typically uncover what happened, whereas investigations such as a root cause analysis explain why the incident occurred and what preventive strategies can be developed and implemented [11], [12]. Virtually no research in healthcare has evaluated the effectiveness of interventions in reducing the probability that an event will recur. Offering a PSRS to frontline caregivers may help identify incidents and associated contributing factors and provide information to improve patient safety.

Unlike other high-risk industries, health care has yet to broadly apply incident reporting to improve patient safety [7], [13], [14]. The specific aims of this study were to evaluate the frequency and type of factors involved in incidents reported to a web-based PSRS and address questions that must be answered to enhance the value of PSRS to improve patient safety.

Section snippets

Overall design and study population

We developed a voluntary web-based PSRS, the ICU Safety Reporting System (ICUSRS), to collect incidents in ICUs. This was a prospective cohort study in a diverse group of US ICUs. Detailed descriptions of the development and implementation of the ICUSRS have been published [15], [16]. This system was informed by the experiences of other researchers [17], [18], [19], [20]. All data collected were anonymous to patient and provider. The reporter elected whether to identify their ICU. Data

Results

Of the original 30 ICUs recruited, risk managers declined participation in 7, ICU directors declined participation in 2, and 3 never requested IRB approval. Five additional ICUs were recruited or requested participation; 23 ICUs were actively reporting at the time of this analysis. As of June 30, 2004, 2075 reports were submitted to the ICUSRS.

Table 1 describes volume of reporting per month by ICU. Overall median number of reports per month was 3 (range, 0-18). The largest number of reports by

Discussion

In this national cohort of ICUs, we found that the ICUSRS can serve as a central mechanism to identify hazards. Staff reported 2 or more contributing factors in 3 quarters of the 2075 incidents. This finding demonstrates in health care what safety theorists like James Reason documented in other high-risk industries; incidents are largely the result of system defects [10]. In fact, a trend in the data suggests that incidents with more than 3 types of contributing factors correlated with higher

References (38)

  • T. Brennan et al.

    Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I

    Qual Saf Health Care

    (2004)
  • Palmisano D. Patient safety legislation-an urgent call to action....
  • Patient Safety and Quality Improvement Act of 2005. The Orator.com, Public Law 109-141, 2005,...
  • L. Leape

    Reporting of adverse events

    N Engl J Med

    (2002)
  • C. Billings

    The NASA Aviation Safety Reporting System: lessons learned from voluntary incident reporting

    (1999)
  • C. Vincent

    Understanding and responding to adverse events

    N Engl J Med

    (2003)
  • J. Reason

    Managing the risks of organizational accidents

    (2000)
  • S. Dekker

    The field guide to human error investigations

    (2002)
  • Cited by (0)

    Research supported by the Agency for Healthcare Research and Quality (AHRQ), grant no. U18 HS11902.

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