• Patricia A Nast, Michael Avidan, Carolyn B Harris, Melissa J Krauss, Eric Jacobsohn, Ann Petlin, W Claiborne Dunagan, and Victoria J Fraser.
• Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO 63110, USA. pnast@im.wustl.edu
• J. Thorac. Cardiovasc. Surg. 2005 Oct 1;130(4):1137.

ObjectivesThe objective was to evaluate a new mechanism for reporting and classifying patient safety events to increase reporting and identify patient safety priorities.MethodsA 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.ResultsA 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%).ConclusionsHealth 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.

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