• David A Thompson, Lisa Lubomski, Christine Holzmueller, Albert Wu, Laura Morlock, Maureen Fahey, Fern Dickman, Todd Dorman, and Peter Pronovost.
• Johns Hopkins University Schools of Medicine and Nursing, Baltimore, USA. dthomps1@jhmi.edu
• Jt Comm J Qual Patient Saf. 2005 Oct 1;31(10):585-93.

BackgroundVoluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety.FindingsA voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter.ResultsAll seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems.ConclusionVoluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

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