Error Reporting System Sharply Cuts ICU Mortality

Martha Kerr

January 30, 2003

Jan. 30, 2003 (San Antonio) — Johns Hopkins University researchers have devised the first-ever error reporting system for the intensive care unit (ICU), which has the potential to cut mortality by as much as 30%, its developers reported here Wednesday at the 32nd annual meeting of the Society of Critical Care Medicine (SCCM).

"There are no well-functioning systems [for medical error reporting] in the U.S. — certainly none for the ICU," said Peter Pronovost, MD, PhD, from Johns Hopkins University in Baltimore, Maryland. Six months ago, he and his colleagues in collaboration with the SCCM launched a pilot study of a web-based reporting system that is confidential and anonymous.

The team is meeting here for the first time to evaluate the viability of the system, and they presented the results of the first 300 cases investigated. "The system works and works amazingly well," Dr. Pronovost told Medscape. "Staff are reporting incidents, we're learning what is broken and are working to fix it.... We need to work to move away from blaming people and start focusing on how the system is organized."

The pilot project involved 30 ICUs from a range of hospitals, from academic to urban to rural. Dr. Pronovost said they have found that a significant number of errors occur when physicians give orders that include numbers. A simple remedy that works "amazingly well," he said, is for the staff member who receives the order to repeat the number back. "Forty percent of our mistakes are medication errors. We can fix it without a million-dollar system."

A coinvestigator on the project, Albert W. Wu, MD, MPH, from the Bloomberg School of Public Health at Johns Hopkins, pointed out that "teams are having to make decisions quickly in the ICU. The majority of errors never go anywhere, they are near misses. Doctors and nurses don't learn from those mistakes."

The web-based system is designed after flight aviation systems, Dr. Pronovost said. The reporter is anonymous, and patient name, date, and time are not included in the report. A training form can be seen at

"We've seen two striking problems," Dr. Wu told Medscape. The first is workloads that are too heavy and the second is communication problems among staff under pressure, which the "check-back" method of reiterating drug and dosage greatly alleviates.

Another solution that Dr. Pronovost advocates is having an intensivist lead every ICU team, instead of the admitting physician being in charge of the patient. "That could lead to 162,000 lives per year saved," he predicted. "It could cut mortality by 30%."

Dr. Pronovost said that the pilot program has increased physicians' awareness of the potential for error and the true number of near misses that occur with each patient. "Virtually every patient in the ICU experiences a near miss," he said.

Dr. Wu noted that a culture change is also going to be required. "We need to let doctors and nurses know that it is OK to report mistakes." Because the system is web-based, he said that the reporter can fill out a report from any computer, so that it is truly confidential and anonymous.

"Estimates from the Institute of Medicine indicate that between 44,000 and 98,000 people die each year from [medical errors]. If you take the lower number, that is more people who die each year from breast cancer, from AIDS, or from motor vehicle accidents.... The greatest opportunity to improve health in this country in the next quarter century is not going to be from new discoveries of magic drugs, it's going to be from delivering care that you know works, safely," Dr. Pronovost asserted.

SCCM 32nd Congress. Presented Jan. 29, 2003.

Reviewed by Gary D. Vogin, MD