585 October 2005 Volume 31 Number 10 T he Institute of Medicine (IOM) recommended voluntary incident reporting systems as a strate- gy to improve patient safety. 1 Systems for report- ing, analyzing, and disseminating information on near misses have been instituted in a number of safety critical industries, including nuclear power technology and avia- tion. 2,3 The Aviation Safety Reporting System is credited with substantially improving the safety of airline travel in the United States during the past three decades. 1,4 The Australian Incident Monitoring System was one of the first reporting systems in health care to implement a vol- untary reporting system in multiple hospitals. 5 By 1999, it had collected more than 17,000 reports from 100 ICUs. 6,7 Incident reporting systems can hold providers account- able for performance and provide information about flawed systems that lead to improved safety—two purpos- es that “can prove difficult to satisfy simultaneously.” 1(p.74) Reporting systems that primarily hold providers account- able are generally operated by state governments as “mandatory reporting systems” and focus on errors asso- ciated with serious injury or death. Conversely, “voluntary reporting systems” are generally used internally within a hospital to improve patient safety. 8 Health care incident reporting is often fragmented, with most hospitals operating multiple reporting systems. Some hospitals use external reporting systems such as U.S. Pharmacopeia’s MedMarx system (Rockville, MD; http://www.medmarx.com) and the Institute for Safe Integrating the Intensive Care Unit Safety Reporting System with Existing Incident Reporting Systems Information Technology David A. Thompson, D.N.Sc., M.S., R.N. Lisa Lubomski, Ph.D. Christine Holzmueller, B.L.A. Albert Wu, M.D., M.P.H. Laura Morlock, Ph.D. Maureen Fahey, M.L.A. Fern Dickman, M.P.H. Todd Dorman, M.D. Peter Pronovost, M.D., Ph.D. Background: Voluntary incident reporting systems that identify risks can be integrated into existing hospi- tal 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 hospi- tals' 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 exist- ing 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 com- pleted 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. Article-at-a-Glance