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

J Thorac Cardiovasc Surg. 2005 Oct;130(4):1137. doi: 10.1016/j.jtcvs.2005.06.003.


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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Cardiovascular Diseases / classification
  • Cardiovascular Diseases / therapy*
  • Cardiovascular Surgical Procedures* / adverse effects
  • Female
  • Forms and Records Control
  • Hospitals, Teaching / standards
  • Humans
  • Intensive Care Units / standards*
  • Male
  • Medical Errors / classification*
  • Medical Errors / prevention & control
  • Middle Aged
  • Missouri
  • Patient Identification Systems
  • Postoperative Care / standards*
  • Postoperative Complications / classification
  • Postoperative Complications / etiology
  • Postoperative Complications / prevention & control
  • Risk Management / methods*
  • Risk Management / statistics & numerical data
  • Safety Management
  • Severity of Illness Index