HEALTH CARE INCIDENT REPORTING TO IMPROVE QUALITY

Incident reporting that identifies broken systems is needed to improve patient safety.^[32] Unfortunately, the potential of incident reporting has not been realized in health care, in which incident reporting tends to be punitive and focused on people rather than systems. We need to move from reporting systems that focus on blame to those that evaluate how we organize our work and include expert analysis and feedback. The National Health Service in the United Kingdom and the Intensive Care Unit Safety Reporting System (ICUSRS) project are examples of such incident reporting systems.

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In the ICUSRS, researchers and caregivers created a web-based anonymous reporting system that seeks to uncover the unsafe conditions that could lead to patient harm. They partnered with the Society for Critical Care Medicine to provide expert analysis and feedback to members on lessons learned regarding how to improve patient safety. The ICUSRS has assembled a community of 22 ICUs across the United States and is realizing the potential for incident reporting to improve safety. It has received more than 1500 reports and identified significant opportunities to improve safety, with plans to make it widely available to all ICUs and expand to other inpatient settings.^[33] This type of

TABLE 81-1 -- System factors used in the ICUSRS that could have contributed to an incident

Factor Type Contributing to Incident	Definition	Examples
Patient Factors
Condition (e.g., complexity, seriousness, agitation)	Clinical or social characteristics of a patient that contribute to an adverse event	Patient does not speak English.
Language or communication		Patient refuses therapy.
Personality and social factors
Task Factors
Availability of protocols	Characteristics of a specific task that contribute to an adverse event	Lack of protocol to guide therapy
Availability of test results		Test results not available for provider to make an informed care decision
Accuracy of test results
Provider Factors
Fatigue	Characteristics or state of an individual provider that contributes to an adverse event	At the end of a double shift and provider forgets to give a medication
Motivation and attitude
Physical or mental health		Providers do not think they need help or advice with a complicated procedure.
Team Factors
Verbal or written communication during hand-off	Characteristics of the work team that contribute to an adverse event	Lack of standard procedure during hand-offs at shift change
Verbal or written communication during care		Perceived barrier for speaking up
Verbal or written communication during crisis
Team structure and leadership
Training and Education
Knowledge, skills, and competence	Aspects of providers' training and/or education that limit their ability to care for a patient and/or contribute to an incident	Lack of skill in performing procedure
Supervision and seeking help		Inexperienced nurse not supervised while mixing a medication concentration
Follow established protocol
ICU Environment
Staffing levels	Characteristics of the work environment that contribute to an adverse event	Workload in the ICU
Skills mix		Broken equipment
Workload
Availability and maintenance of equipment
Administrative and managerial support
Physical environment (e.g., lack of space, noise)
Institutional Environment
Financial resources	Decisions or lack thereof by management that contribute to an adverse event	Pressure to treat more patients
Time pressures		Limited financial resources
ICU, intensive care unit; ICUSRS, Intensive Care Unit Safety Reporting System.
From Pronovost PJ, Nolan T, Zeger S, et al: Measuring quality and safety: Balancing validity and burden. Lancet (in press).

reporting system could be widely applied in anesthesiology and provide an efficient means to learn what is broken.

There is debate about whether incident reports should focus on incidents (mistakes) or harm, regardless of whether there was a mistake, in seeking to identify the system factors associated with mistakes.^{[34] [35]} Although much harm to patients is preventable, it is unlikely that reporting harm will lead to meaningful improvements unless accompanied by standardized data on system variables such as how we organize and deliver care that may be associated with the harm.^[33] At a single hospital, system factors above the level of provider ( Table 81-1 ) may be

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