Journal Article

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

Schuerer DJE, Nast PA, Harris CB, et al. Journal of the American College of Surgeons. 2006;202:881-7.

This Agency for Healthcare Research and Quality (AHRQ)–supported study demonstrated that implementation of a card-based reporting system in place of an existing and underused online one increased reporting rates among both physicians and nurses. Investigators provided education prior to introduction of the new card reporting system as they introduced it, removed it, and reintroduced it to determine the effectiveness. Physician reporting dropped to zero after the card was removed and rose to peak levels after reintroduction. The authors also discuss the differences in the reports themselves, which suggested physicians more frequently report events that caused harm. Given the emphasis on reporting systems, the authors suggest this as an alternative mechanism to encourage reporting from physicians, a group very involved in patient care but infrequently participating in the event reporting process. A past survey study described physician perception of hospital safety and barriers to incident reporting.