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  • Measure Summary
  • NQMC:008549
  • Mar 2011

Planning, organization, and management: does the hospital have a system for notifying and registering adverse events in the ICU?

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in July 2015.

Primary Measure Domain

Clinical Quality Measures: Structure

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess whether the hospital has a system for notifying and registering adverse events in the intensive care unit (ICU).

Rationale

The aim of intensive care medicine is to provide critical patients with the healthcare that they need, ensuring the quality and safety of care. Intensive care medicine is one of the principal components of modern healthcare systems. There is an increasing demand for this resource, which involves high costs.

The quality of care has gradually come to be the central focus of healthcare, and in recent years patient safety has come to represent one of the key aspects of quality. In the case of intensive care medicine, this interest in quality is even more evident, not only because of its social and economic impact, but also because some of the dimensions involved in the quality of care of critical patients take on greater importance: critical patients are more vulnerable, access to critical care is more limited so efforts to distribute resources equitably are more important, scant scientific evidence is available, and the efficiency is limited.

Adverse events (AE) are common in the field of medicine and are related to significant mortality and morbidity, as well as increased stays and costs. Moreover, they diminish patients' and families' satisfaction. Systems for notifying AE enable the analysis of AE and actions to improve the quality of care. These systems also encourage the culture of safety.

Evidence for Rationale

Needham DM, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, Morlock LL, Pronovost PJ. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004 Nov;32(11):2227-33. PubMed External Web Site Policy

Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, Wu AW, Morlock LL. Toward learning from patient safety reporting systems. J Crit Care. 2006 Dec;21(4):305-15. PubMed External Web Site Policy

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Winters BD, Berenholtz SM, Pronovost P. Improving patient safety reporting systems. Crit Care Med. 2007 Apr;35(4):1206-7. PubMed External Web Site Policy

Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care. 2002 Jun;17(2):86-94. PubMed External Web Site Policy

Primary Health Components

Planning; organization; management; notification system; adverse events

Denominator Description

This measure applies to hospitals (one hospital at a time) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The presence of a system for notifying and registering adverse events (AE) in the intensive care unit (ICU) (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Does not apply to this measure

Target Population Gender

Does not apply to this measure

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Unspecified

Denominator Sampling Frame

Health care or public health organization

Denominator (Index) Event or Characteristic

Does not apply to this measure

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
This measure applies to hospitals (one hospital at a time).

Population: Hospital registers.

Exclusions
Unspecified

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
The presence of a system for notifying and registering adverse events (AE) in the intensive care units (ICU)

System for notifying and registering AE:

  • Must be voluntary and anonymous
  • Must make it possible for any professional to notify an AE
  • Must include sentinel events and the analysis of root causes
  • Must provide feedback/each semester: bulletins, warnings, etc.
  • Can function simultaneously with other surveillance systems for specific AE: infections, falls, restraints, etc.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Dichotomous

Interpretation of Score

Desired value is presence of a characteristic

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Prescriptive standard

Prescriptive Standard

Standard: 100%

Evidence for Prescriptive Standard

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Original Title

System for the notification of adverse events.

Measure Collection Name

Quality Indicators in Critically Ill Patients

Measure Set Name

Planning, Organization, and Management

Submitter

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Developer

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Funding Source(s)

Boehringer Laboratories

Composition of the Group that Developed the Measure

Work Group for Planning, Organization, and Management

  • María Cruz Martín Delgado
  • Luis Ángel Domínguez Quintero
  • Francisca Prieto Valderrey
  • Emilio Moreno Millán
  • Francisco Fernández Dorado
  • Blanca Obón Azuara
  • Isabel Gutiérrez Cia
  • Roser Anglés Coll
  • Miguel Soto Ibáñez
  • Juan Roca Guiseris
  • Paz Merino de Cos
  • Joaquín Álvarez Rodríguez

Scientific Coordination:

  • Maria Cruz Martín Delgado
  • Jesús Blanco Varela
  • Lluís Cabré Pericas
  • Pedro Galdos Anuncibay
  • Federico Gordo Vidal

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2011 Mar

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

2016 Jul

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in July 2015.

Source(s)

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Measure Availability

Source available in English External Web Site Policy and Spanish External Web Site Policy from the Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC) Web site.

For more information, contact SEMICYUC at Paseo de la Reina Cristina, 36, 4o D, Madrid, Spain; Phone: +34-91-502-12-13; Fax: +34-91-502-12-14; Web site: www.semicyuc.org External Web Site Policy; E-mail: secretaria@semicyuc.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 2, 2014. The information was verified by the measure developer on April 25, 2014.

The information was reaffirmed by the measure developer on July 2, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The Quality Indicators in Critically Ill Patients update 2011 can be used by any private or public body only for the purposes of research, clinical management, teaching and education, and will not be used for any other purpose. In all cases, full credit to the Spanish Society of Intensive Care Medicine (SEMICYUC) will be granted. The commercial use of the Quality Indicators in Critically Ill Patients update 2011 is explicitly forbidden.

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