The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. the Development and Evaluation of an Incident Reporting System in Intensive Care

Abstract

Intensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.

Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review*

“…FIM was based on the standard AIMS-ICU incident monitoring system (2,3). In the standard AIMS-ICU system, the staff in the ICU were introduced to incident monitoring as part of their orientation to the ICU.…”

“…Although conventional incident reporting underestimates the true rate of problems (19), voluntary and anonymous incident reporting has been used with success in anesthesiology (20 -22) and intensive care (2,3,10). The Australian Incident Monitoring Study in Intensive Care (AIMS-ICU) involves the voluntary and anonymous reporting of incidents by all intensive care unit (ICU) staff in participating units.…”

Medical errors and adverse events: Focus on the Intensive Care Unit

“…The system is assessed, not individual staff members. The potential contribution of incident monitoring to Quality of Care and patient safety in the ICU has been proven long time ago [22]. The contextual information gathered by incident monitoring will become much more useful, when specific incidents can be analyzed, using a framework for apportioning the various contributing factors (latent errors), behavioural factors (active errors) and chance.…”

Neue Trainingsformen und Erhöhung der Patientensicherheit

“…Die Beschäftigung mit diesen kleinen Fehlern erhöht außerdem die Aufmerksamkeit der Beteiligten und trägt dazu bei, nicht zu sorglos zu werden [51] ("Never forget to be afraid"). Wir brauchen sogenannte "Critical-incident-reporting"-Systeme [2,5,56].…”