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J Thorac Cardiovasc Surg 2005;130:1137
© 2005 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

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

Patricia A. Nast, BSN a , * , Michael Avidan, MD b , Carolyn B. Harris, MPH a , Melissa J. Krauss, MPH a , Eric Jacobsohn, MD b , Ann Petlin, RN, MSN c , W. Claiborne Dunagan, MD a , Victoria J. Fraser, MD a

a Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine
b Department of Anesthesiology and Division of Cardiothoracic Surgery, Washington University School of Medicine
c Department of Nursing, Surgical Services Division, Barnes-Jewish Hospital, St Louis, Mo

* Address for reprints: Patricia A. Nast, BSN, RN, Washington University School of Medicine, Department of Internal Medicine, Campus Box 8051, 660 S. Euclid Ave, St Louis, MO 63110 (Email: pnast{at}im.wustl.edu).

OBJECTIVES: The objective was to evaluate a new mechanism for reporting and classifying patient safety events to increase reporting and identify patient safety priorities.

METHODS: A voluntary patient safety event reporting system accessible by all health care workers was implemented in the Cardiothoracic Intensive Care and Post Anesthesia Care Units. Information collected included patient identifiers; date, time, and location of report and event; type and description of event; and severity score. Narrative descriptions of events were analyzed and coded to describe when in the care process the event occurred, what occurred, and a causal classification of why the event occurred.

RESULTS: A total of 163 reports describing 157 events were received. These included 121 events reported from the intensive care unit (25.3 reported events per 1000 patient-days), a 3-fold increase compared with the preexisting on-line reporting system. A total of 113 reports (69%) came from nurses, 31 from physicians (19%), and 10 from other staff (6%). A majority of events (85, 54%) reached the patient but caused no harm. Multiple causes were identified for the majority of events. The most frequent causes were related to human factors (48%) and organizational factors (34%).

CONCLUSIONS: Health care workers were willing to use the patient safety event reporting system, which yielded a broad range of patient safety data. Patient safety events are multifaceted and often have multiple causal factors. Application of a causal classification model for patient safety event coding in the intensive care and preoperative and postoperative care units is feasible and facilitates local communication of important event-related information.

2; 11; 12; 18; 25; 34






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