Quality/Medical Errors

New Web-based ICU safety reporting system may have the potential to reduce medical errors at ICUs across the country

The voluntary and anonymous Intensive Care Unit Safety Reporting System (ICUSRS), modeled after the Aviation Safety Reporting System that has been highly successful in identifying and rectifying safety problems in aviation, has the potential to do the same for intensive care units (ICUs). The Web-based system, developed with support from the Agency for Healthcare Research and Quality (HS11902), currently includes reports from 23 ICUs throughout the United States. During the first year, a total of 854 reports were submitted by 18 ICUs, according to Peter J. Pronovost, M.D., Ph.D., of the Johns Hopkins University School of Medicine, and his colleagues.

Reports revealed that inadequate training and education were major factors contributing to incidents. Team factors also contributed to incidents, particularly poor written and verbal communication among team members and flawed team structure. About 72 percent of reported incidents were due to more than one system factor. Most incidents did not lead to harm, although 21 percent of incidents led to physical injury, and 14 percent of incidents were anticipated to increase ICU length of stay.

On each report, an anonymous filer identifies system factors that contributed to a medical error or near-miss. These include training and education factors (lack of knowledge or skills or failure to follow an established protocol); team factors (verbal or written communication problems during patient hand-offs at shift changes, routine care, or crises); patient factors (for example, agitation or language barriers); ICU environment (staffing levels, workload, and availability of equipment); provider factors (for example, fatigue and attitude); task factors (availability of protocols or test results); and institutional environment (financial resources and time constraints). Data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter to help them identify trends within their own ICU and other ICUs and learn ways to improve safety.

See "Creating the Web-based Intensive Care Unit Safety Reporting System," by Christine G. Holzmueller, Dr. Pronovost, Fern Dickman, M.P.H., and others in the March-April 2005 Journal of the American Medical Informatics Association 12, pp. 130-139.

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