Development of the ICU Safety Reporting System

Abstract

The Intensive Care Unit Safety Reporting System (ICUSRS) is a voluntary web-based reporting system to improve patient safety in intensive care units (ICUs). ICUSRS was designed to be non-punitive and confidential, employ expert analysis, provide timely analysis and feedback, and be systems oriented, democratic, low-burden, web-based, simple, and sustainable. Important considerations included coordination with other reporting systems, and concerns about confidentiality and liability. In the first year, 18 U.S. ICUs (2 pediatric and 16 adult) participated; 50% were academic medical centers, 44% community teaching hospitals, and 6% community hospitals. Adult ICUs were 13% surgical, 19% medical, 13% cardiac surgical, 13% mixed medical/surgical, and 24% other. ICUSRS was constructed for Windows. Reporting is anonymous to both patient and reporter. The form begins with a verbatim account of the incident, followed by close-ended questions about factors that might have contributed to, minimized, and prevented similar incidents. Outcomes include death, physical injury, discomfort, dissatisfaction, and economic outcomes. Reporters can review and edit incidents before submitting. After submission, reports are stripped of identifiers, analyzed by ICU safety experts, and fed back to each site. In the first month of participation, sites averaged 4.8 reports. Mean reporting peaked at 7.5 in month 11 and was 4.3 in month 12. There was wide variability in reporting among sites. Half of the reports described near misses. The ICUSRS incorporates features of an effective reporting system and could be used by front line health care providers.