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PSNet: Patient Safety Network
Journal Article

Development of the ICU safety reporting system.

Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.

This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. The investigators aimed to create an easy-to-use system that assists in characterizing captured incidents and allows opportunity for feedback. Discussion includes details of the design features, a table of the system-based factors contributing to reported incidents, and several screen shots of the reporting system itself. Initial data collected after implementation demonstrated wide variability in use, but consistency existed in the types of incidents reported—nearly one of every two being a near miss. The authors suggest that wide adoption of this type of reporting system, coordinated by a professional organization, may lead to data-generated improvements in care.