Building a Better Incident Reporting System: Perspectives from a Multisite Project

• Objective: To discuss key issues that emerged during the design and implementation of a Web-based incident reporting system. • Setting: 23 intensive care units in the United States. • Project description: The Web-based reporting form was developed and implemented as part of the Intensive Care Unit Safety Reporting System project funded by the Agency for Healthcare Research and Quality. Unit staff members were trained on the rationale and conceptual basis of the project and the use of the reporting form. They were encouraged to report both adverse events (incidents resulting in patient harm) and near misses (incidents that do not result in patient harm). The first site began reporting in July 2002, with additional sites enrolled sequentially throughout the year. • Results: The experience with this project suggests that 4 areas should be targeted to maximize the success of incident reporting systems: integration with existing reporting structures, promoting incident reporting by staff, coding and analysis of event reports, and use of incident reports to improve patient safety. Multiple reporting systems within a single hospital or health system will not be feasible, and the health care community must consolidate reporting systems and consider how to share data from a single system that is useful to multiple stakeholders. To encourage participation, reporting systems must be user-friendly, anonymous, confidential, and nonpunitive and must provide timely feedback to users. Effective coding methods are key to both data analysis and reporting data back to the sites. The value of such coding methods should be measured in terms of their usefulness to caregivers for improving patient safety. • Conclusion: Additional research is needed to better understand how to code, analyze, and report incidents so that caregivers and leaders can use the information to improve patient safety. The problem of adverse events represents a significant challenge for U.S. hospitals. Patients in intensive care units (ICUs) especially may be at risk for exposure to an adverse event because of the complexity of their illnesses and care. It has been estimated that each patient admitted to an ICU is at risk for exposure to 1.7 errors per day of admission [1]. Following publication of the Institute of Medicine’s report To Err Is Human, interest in the development and use of incident reporting systems as a means to address the problem of adverse events has grown [2]. We developed and implemented a Web-based incident reporting system as part of an Agency for Healthcare Research and Quality (AHRQ) demonstration project designed to gather and report medical error data. The aim of the Intensive Care Unit Safety Reporting System (ICUSRS) project is to understand the system factors associated with the occurrence of adverse events, both events that result in patient harm and “near misses” in which harm was avoided. From our experience with the ICUSRS, we believe that there are 4 key areas that should be targeted to maximize the success of incident reporting systems: integration with existing reporting structures, promoting incident reporting by staff, coding and analysis of event reports, and use of incident reports to fix what is broken in health care delivery. We discuss each of these topics as it relates to our experience with the ICUSRS.