ICU incident reporting systems

Albert W Wu, Peter Pronovost, Laura Morlock

Research output: Contribution to journalArticle

Abstract

Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other highrisk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent. We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Healthcare Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Research and Quality.

Original languageEnglish (US)
Pages (from-to)86-94
Number of pages9
JournalJournal of Critical Care
Volume17
Issue number2
DOIs
StatePublished - 2002

Fingerprint

Risk Management
Intensive Care Units
Critical Care
Radiologic Health
Mandatory Reporting
Delivery of Health Care
Safety
Aviation
Health Services Research
Social Responsibility
United States Food and Drug Administration
Patient Safety
Systems Analysis
Industry
Equipment and Supplies
Incidence

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

ICU incident reporting systems. / Wu, Albert W; Pronovost, Peter; Morlock, Laura.

In: Journal of Critical Care, Vol. 17, No. 2, 2002, p. 86-94.

Research output: Contribution to journalArticle

Wu, Albert W ; Pronovost, Peter ; Morlock, Laura. / ICU incident reporting systems. In: Journal of Critical Care. 2002 ; Vol. 17, No. 2. pp. 86-94.
@article{ed163b9c8d91443c871937a43b73c838,
title = "ICU incident reporting systems",
abstract = "Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other highrisk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent. We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Healthcare Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Research and Quality.",
author = "Wu, {Albert W} and Peter Pronovost and Laura Morlock",
year = "2002",
doi = "10.1053/jcrc.2002.35100",
language = "English (US)",
volume = "17",
pages = "86--94",
journal = "Journal of Critical Care",
issn = "0883-9441",
publisher = "Elsevier BV",
number = "2",

}

TY - JOUR

T1 - ICU incident reporting systems

AU - Wu, Albert W

AU - Pronovost, Peter

AU - Morlock, Laura

PY - 2002

Y1 - 2002

N2 - Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other highrisk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent. We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Healthcare Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Research and Quality.

AB - Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other highrisk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent. We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Healthcare Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Research and Quality.

UR - http://www.scopus.com/inward/record.url?scp=0036297148&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0036297148&partnerID=8YFLogxK

U2 - 10.1053/jcrc.2002.35100

DO - 10.1053/jcrc.2002.35100

M3 - Article

C2 - 12096371

AN - SCOPUS:0036297148

VL - 17

SP - 86

EP - 94

JO - Journal of Critical Care

JF - Journal of Critical Care

SN - 0883-9441

IS - 2

ER -