[Anonymous critical incident reporting system. Implementation in an intensive care unit]

Area of Science:

• Medicine
• Healthcare Management
• Patient Safety

Background:

• An anonymous reporting system for critical incidents was established in 2003.
• The system was later adapted for intranet use and expanded to the intensive care unit (ICU).

Purpose of the Study:

• To analyze the types and causes of critical incidents reported in an ICU setting.
• To understand the incidence and potential effects of errors in intensive care.

Main Methods:

• Implementation of an anonymous reporting system in the Department of Anaesthesiology and Intensive Care Medicine.
• Modification to an intranet-based system and extension to the ICU.
• Analysis of 70 anonymous reports registered over the first 18 months.

Main Results:

• 70 anonymous reports were collected from the ICU within 18 months.
• Common errors included fluid management (most frequent), airway management, cardiovascular management, neurological issues, and drug administration.
• Primary causes identified were lack of attention, insufficient checks, high nurse workload, experience levels, and communication deficits.

Conclusions:

• The ICU setting experiences a notable incidence of critical incidents.
• Understanding error patterns and causes is crucial for improving patient safety in intensive care.
• Addressing factors like attention, workload, and communication can mitigate risks.