Patient safety event reporting in critical care: a study of three intensive care units.

Carolyn B Harris; Melissa J Krauss; Craig M Coopersmith; Michael Avidan; Patricia A Nast; Marin H Kollef; Claiborne Dunagan; Victoria J Fraser

Study

Patient safety event reporting in critical care: a study of three intensive care units.

March 21, 2007

Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35(4):1068-76.

View more articles from the same authors.

The investigators implemented a voluntary card-based error-reporting program and compared the results to those of an existing Web-based program. They found that reporting increased significantly with the card-based system.

PubMed citation

Available at

Related Resources From the Same Author(s)

Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.

October 26, 2005

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

June 14, 2006

Medical error disclosure among pediatricians: choosing carefully what we might say to parents.

October 15, 2008

The attitudes and experiences of trainees regarding disclosing medical errors to patients.

March 19, 2008

How trainees would disclose medical errors: educational implications for training programmes.

April 13, 2011

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

February 7, 2007

Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.

July 13, 2005

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

May 24, 2006

Reducing medication prescribing errors in a teaching hospital.

August 27, 2008

The emotional impact of medical errors on practicing physicians in the United States and Canada.

August 1, 2007

Lost opportunities: how physicians communicate about medical errors.

January 23, 2008

Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.

September 10, 2014

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

August 16, 2006

Implementing a commercial rule base as a medication order safety net.

August 31, 2005

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

August 16, 2006

Risk managers, physicians, and disclosure of harmful medical errors.

February 24, 2010

Patients' concerns about medical errors during hospitalization.

January 3, 2007

Patient concerns about medical errors in emergency departments.

March 6, 2005

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

July 13, 2011

Patients' and physicians' attitudes regarding the disclosure of medical errors.

March 6, 2005

Hospitalized patients' attitudes about and participation in error prevention.

May 17, 2006

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the Prevention Epicenter Program.

January 18, 2006

An observational study of postoperative handoff standardization failures.

June 23, 2021

Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.

July 8, 2009

A decade of preventing harm.

June 19, 2019

The cost of serious fall-related injuries at three midwestern hospitals.

February 2, 2011

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

July 29, 2009

Competencies for patient safety and quality improvement: a synthesis of recommendations in influential position papers.

April 6, 2016

An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients.

October 6, 2010

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

May 23, 2012

Targeted versus universal decolonization to prevent ICU infection.

May 1, 2013

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

May 11, 2022

Frontiers in measuring structural racism and its health effects.

September 21, 2022

Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention.

September 21, 2022

Staffing matters—every shift.

December 12, 2012

Impact of computerized physician order entry alerts on prescribing in older patients.

March 25, 2015

Nurse burnout syndrome and work environment impact patient safety grade.

August 25, 2021

Influence of unit-level staffing on medication errors and falls in military hospitals.

May 18, 2011

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

March 2, 2016

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

Systematic review of intraoperative anesthesia handoffs and handoff tools.

July 21, 2021

Automated and electronically assisted hand hygiene monitoring systems: a systematic review.

June 18, 2014

Closing the gap and raising the bar: assessing board competency in quality and safety.

May 10, 2017

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

November 13, 2013

Safe prescribing: an educational intervention for medical students.

July 19, 2006

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

September 29, 2010

Junior doctors' views on reporting concerns about patient safety: a qualitative study.

June 17, 2015

Understanding the cognitive work of nursing in the acute care environment.

October 19, 2005

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

September 23, 2015

Accuracy of harm scores entered into an event reporting system.

April 22, 2015

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

November 2, 2022

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

Filling the gap: simulation-based crisis resource management training for emergency medicine residents.

May 2, 2018

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

September 9, 2015

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

November 6, 2019

Implementation of a patient safety program at a tertiary health system: a longitudinal analysis of interventions and serious safety events.

May 9, 2018

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement.

November 23, 2011

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Diagnostic reliability in teledermatology: a systematic review and a meta-analysis.

August 30, 2023

SAFER Care: improving caregiver comprehension of discharge instructions.

March 31, 2021

PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.

June 29, 2016

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

February 16, 2022

A communication training program to encourage speaking-up behavior in surgical oncology.

October 11, 2017

Nurse well-being: a concept analysis.

August 17, 2022

The association of shift-level nurse staffing with adverse patient events.

March 23, 2011

Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement.

April 27, 2016

The Veterans Affairs National Quality Scholars Program: a model for interprofessional education in quality and safety.

August 22, 2012

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

February 8, 2017

Implementing a distraction-free practice with the Red Zone Medication Safety initiative.

June 8, 2016

Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence.

June 2, 2021

Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator.

January 20, 2010

Views of practicing physicians and the public on medical errors.

March 27, 2005

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Effect of reducing interns' work hours on serious medical errors in intensive care units.

March 27, 2005

How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?

November 21, 2012

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Introduction of checklists at daily progress notes improves patient care among the gynecological oncology service.

December 5, 2012

Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.

April 9, 2014

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019.

September 30, 2020

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2018.

August 21, 2019

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

The effect of contact precautions on frequency of hospital adverse events.

December 9, 2015

The morbidity and mortality meeting: time for a different approach?

December 2, 2015

Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures.

September 2, 2015

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

September 1, 2021

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program.

May 2, 2012

New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature and analysis.

September 1, 2010

The additional cost of perioperative medication errors

July 5, 2023

Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care.

August 5, 2015

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

January 26, 2022

How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?

January 13, 2010

Using prospective clinical surveillance to identify adverse events in hospital.

March 30, 2011

Body CT: technical advances for improving safety.

August 3, 2011

Proposal for a 'surgical checklist' for ambulatory oral surgery.

June 15, 2011

Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.

August 9, 2017

Self-assessment and learning motivation in the second victim phenomenon.

February 1, 2023

Costs associated with surgical site infections in Veterans Affairs hospitals.

July 9, 2014

An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology.

January 27, 2021

Related Resources

Multifaceted intervention to improve patient safety incident reporting in intensive care units.

September 13, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

February 10, 2021

Association of physician burnout with suicidal ideation and medical errors.

January 27, 2021

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

August 28, 2019

Investigating the impact of intensive care unit interruptions on patient safety events and electronic health records use: an observational study.

July 24, 2019

New persistent opioid use after postoperative intensive care in US veterans.

June 19, 2019

Intensive care medicine in 2050: preventing harm.

May 1, 2019

What's in a name? Provider perception of injured John Doe patients.

April 3, 2019

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

Data omission by physician trainees on ICU rounds.

February 6, 2019

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Race differences in reported harmful patient safety events in healthcare system high reliability organizations.

January 23, 2019

WebM&M Cases

Critical Order Set Change and Critical Limb Ischemia

January 1, 2019

Use of a novel, electronic health record–centered, interprofessional ICU rounding simulation to understand latent safety issues.

October 24, 2018

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.

February 21, 2018

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

An ethnographic study of health information technology use in three intensive care units.

August 30, 2017

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events.

June 7, 2017

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

May 10, 2017

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

May 3, 2017

February 8, 2017

Accuracy of laboratory data communication on ICU daily rounds using an electronic health record.

October 12, 2016

Nurse workload and inexperienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: a seven-year prospective study.

August 10, 2016

Frequency of passive EHR alerts in the ICU: another form of alert fatigue?

July 27, 2016

See More About The Topic

Intensive Care Units

Health Care Providers

Health Care Executives and Administrators

Information Professionals

Critical Care

Patient safety event reporting in critical care: a study of three intensive care units.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Patient safety event reporting in critical care: a study of three intensive care units.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site