Research Project

Intensive Care Unit Safety Reporting System (ICUSRS)            

Project Description: 
In their report, “To Err Is Human,” (1) the Institute of Medicine (IOM) called attention to health care errors as a nationwide patient safety problem, responsible for a significant number of deaths each year.  The report identified system failures, rather than individual incompetence, as the primary cause of these errors and noted that attempts to track and reduce health care errors lag far behind safety improvements in other high risk industries.  The overall goal of this project is to improve patient safety in intensive care units (ICU) by identifying and eliminating system failures that lead to errors in care and increase risk of harm to patient.

The ICUSRS is a web-based system for reporting incidents whether or not they lead to harm.  An incident is an event or circumstance that could have (near miss), or did (adverse event) lead to an unintended and/or unnecessary harm to a person. Reporting of incidents is voluntary and anonymous and data collected kept confidential.   Information collected includes a narrative description of the incident, type of event, contextual information about the patient and staff without identifiers, predisposing and limiting factors, specific system factors, and what measures could be taken to prevent similar incidents in the future. The ICUSRS places emphasis on eliciting system factors that contributed to the incident(s), such as the availability of adequate equipment, under staffing, work practices, policies and protocols.  Data collected undergoes expert analysis to identify system defects and recurrent patterns.  Lessons learned are shared with ICUs collaborating in the form of a monthly report and case discussions. 

We have also partnered with the Society for Critical Care Medicine to help disseminate study findings.  A quality corner is available on the SCCM website where safety tips and case discussions are posted and a column dedicated to patient safety recommendations in Critical Connections, a quarterly SCCM publication. 

Specific Aims:

1. To implement in a cohort of ICUs a web-based safety reporting system (ICUSRS) that incorporates a systems approach in the reporting and analysis of incidents;
2. To compare the information provided through reporting near misses vs. adverse events with respect to both the quantity and content of error reporting, as well as the  opportunities identified to improve safety;
3. To examine providers’ perceptions regarding the reporting system, as well as the effects of participation on safety-related attitudes;
4. To explore the usefulness of this ICU error reporting system for safety improvement initiatives at the institutional and professional society levels.