Integrating the Intensive Care Unit Safety Reporting System with Existing Incident Reporting Systems

Authors: Thompson, David A.; Lubomski, Lisa; Holzmueller, Christine; Wu, Albert; Morlock, Laura; Fahey, Maureen; Dickman, Fern; Dorman, Todd; Pronovost, Peter

Source: Joint Commission Journal on Quality and Patient Safety, Volume 31, Number 10, October 2005 , pp. 585-593(9)

Publisher: Joint Commission Resources

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Abstract:

Background: Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety.

Findings: A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the existing systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter.

Results: All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems.

Conclusion: Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

Document Type: Miscellaneous

Publication date: 2005-10-01

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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

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Integrating the Intensive Care Unit Safety Reporting System with Existing Incident Reporting Systems

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