THE AUSTRALIAN INCIDENT MONITORING STUDY IN INTENSIVE-CARE - AIMS-ICU- THE DEVELOPMENT AND EVALUATION OF AN INCIDENT REPORTING SYSTEM IN INTENSIVE-CARE

Intensive care units are complex, dynamic patient management environme nts. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study obje ctives were to develop and evaluate an incident reporting system. A re port form was designed eliciting a description of the incident, contex tual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of ea rlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback que stionnaires were used to assess staff attitudes and understanding, pro ject design and organization. These demonstrated a positive attitude a nd good understanding by more than 90% participants. Errors in communi cation, technique, problem recognition and charting were the predispos ing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for im proving patient safety in intensive care.