ADVERSE INCIDENT REPORTING IN INTENSIVE-CARE

This prospective, observational, anonymous incident reporting study ai med to identify and correct factors leading to reduced patient safety in intensive care. An incident was any event which caused or had the p otential to cause harm to the patient, but included problems in policy or procedure. Reports were discussed at monthly meetings. Of 390 inci dents, 106 occasioned ''actual'' harm and 284 ''potential'' harm. Ther e was one death, 86 severe complications and 88 complications of minor severity. Most were transient but the effects of 24 lasted up to a we ek. Most incidents affected cardiovascular and respiratory systems. In cident categories involved drugs, equipment, management or procedures. Incident causes were knowledge-based, rule-based, technical, slip/lap se, no error or unclassifiable. The study has identified some human an d equipment performance problems in our intensive care unit. Correctio n of these should lead to a reduction in the future incidence of those events and hence an increased level of patient safety.