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Fern Dickman

Publications and source records attributed to Fern Dickman.

3 recordsLinked to original sources

Toward learning from patient safety reporting systems.

PURPOSE: To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS: Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS: Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS: The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Adult↗

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

BACKGROUND: Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety. FINDINGS: A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter. RESULTS: All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems. CONCLUSION: Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

Hospital Information Systems↗

Creating the web-based intensive care unit safety reporting system.

In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter.

Computer Communication Networks↗