Patient safety event reporting in critical care: a study of three intensive care units.

OBJECTIVE: To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. DESIGN: Prospective, single-center, interventional study. SETTING: A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. PATIENTS: Adult patients admitted to these three study ICUs. INTERVENTIONS: Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. MEASUREMENTS AND MAIN RESULTS: During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p < .001). CONCLUSIONS: This card-based reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal important preferences and priorities for reporting medical errors and patient safety events.

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

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

Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.

OBJECTIVES: The objective was to evaluate a new mechanism for reporting and classifying patient safety events to increase reporting and identify patient safety priorities. METHODS: A voluntary patient safety event reporting system accessible by all health care workers was implemented in the Cardiothoracic Intensive Care and Post Anesthesia Care Units. Information collected included patient identifiers; date, time, and location of report and event; type and description of event; and severity score. Narrative descriptions of events were analyzed and coded to describe when in the care process the event occurred, what occurred, and a causal classification of why the event occurred. RESULTS: A total of 163 reports describing 157 events were received. These included 121 events reported from the intensive care unit (25.3 reported events per 1000 patient-days), a 3-fold increase compared with the preexisting on-line reporting system. A total of 113 reports (69%) came from nurses, 31 from physicians (19%), and 10 from other staff (6%). A majority of events (85, 54%) reached the patient but caused no harm. Multiple causes were identified for the majority of events. The most frequent causes were related to human factors (48%) and organizational factors (34%). CONCLUSIONS: Health care workers were willing to use the patient safety event reporting system, which yielded a broad range of patient safety data. Patient safety events are multifaceted and often have multiple causal factors. Application of a causal classification model for patient safety event coding in the intensive care and preoperative and postoperative care units is feasible and facilitates local communication of important event-related information.

Characteristics and circumstances of falls in a hospital setting: a prospective analysis.

OBJECTIVE: To describe the epidemiology of hospital inpatient falls, including characteristics of patients who fall, circumstances of falls, and fall-related injuries. DESIGN: Prospective descriptive study of inpatient falls. Data on patient characteristics, fall circumstances, and injury were collected through interviews with patients and/or nurses and review of adverse event reports and medical records. Fall rates and nurse staffing levels were compared by service. SETTING: A 1,300-bed urban academic hospital over 13 weeks. PATIENTS: All inpatient falls reported for medicine, cardiology, neurology, orthopedics, surgery, oncology, and women and infants services during the study period were included. Falls in the psychiatry service and falls during physical therapy sessions were excluded. MEASUREMENTS AND MAIN RESULTS: A total of 183 patients fell during the study period. The average age of patients who fell was 63.4 years (range 17 to 96). Many falls were unassisted (79%) and occurred in the patient's room (85%), during the evening/overnight (59%), and during ambulation (19%). Half of the falls (50%) were elimination related, which was more common in patients over 65 years old (83% vs 48%; P <.001). Elimination-related falls increased the risk of fall-related injury (adjusted odds ratio, 2.4; 95% confidence interval 1.1 to 5.3). The medicine and neurology services had the highest fall rates (both were 6.12 falls per 1,000 patient-days), and the highest patient to nurse ratios (6.5 and 5.3, respectively). CONCLUSIONS: Falls in the hospital affect young as well as older patients, are often unassisted, and involve elimination-related activities. Further studies are necessary to prevent hospital falls and reduce fall injury rates.