Difficulties reporting system in intensive care

In 2005, Belluno Health Authority's Resuscitation Unit took part in a regional project coordinated by Veneto Regional Health and Social Services to test an incident reporting system. The main aims were to experiment an electronic incident reporting sheet and the relative computerised procedure for data entry and analysis with the aim of developing an incident rep o rting system. The Australian Incident Monitoring System (AIMS) was designed to obtain information about the event, the context and concomitant causes. We observed 58 anonymous incident reports over a six-month period. The main incidents include issues relating to the management of medication, the airways, catheters and equipment. Most incidents had modest consequences or led to temporary disability and they often caused longer hospitalisation or further treatment and investigations. Communication problems, inadequate supervision, poor teamwork and difficulties in applying procedures and protocols were the contributory factors most frequently identified as the concomitant causes of the incidents. The report sheet and experience as a whole were evaluated favourably by the operators involved. This reporting system does not provide the real frequency of the adverse events, but it does provide useful information for improving patient safety.