• Roy Ilan, Mae Squires, Andrew Day, and Christina Panopoulos.
• Department of Medicine, Queen's University, Kingston General Hospital, Kingston, ON, Canada K7L 3N6. ilanr@kgh.kari.net
• J Crit Care. 2011 Aug 1;26(4):431.e11-8.

PurposeThe aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action.Materials And MethodsA prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required.ResultsDuring the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards.ConclusionsAfter the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.Copyright © 2011 Elsevier Inc. All rights reserved.

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