Adverse Event Reporting and Quality Improvement in the Intensive Care Unit.

Patients in the intensive care unit are at high risk for experiencing adverse events and errors. The high-acuity health care needs of these vulnerable patients expose them to numerous medications, procedures, and health care providers. The occurrence of adverse events is associated with detriments to patient outcomes including increased mortality. Adverse event reporting is the most commonly used event-detection tool, but it should also be complimented with other tools such as trigger tools, chart review, and direct observation. Although adverse event reporting is essential for continuous improvement processes and is associated with improvements in safety culture, it remains significantly underutilized.