Intensive care unit errors: detection and reporting to improve outcomes

Most efforts to identify and investigate errors in medicine have focused on active failures and general provider behaviors. We believe that the greatest improvements in error identification and management in the intensive care unit will be achieved by focusing on the intensive care unit's organizational characteristics. The results of three recent studies suggest that differences in intensive care unit organizational characteristics are significantly related to variation in the risk-adjusted morbidity and mortality. Physicians must assume greater leadership in creation of these safe systems for intensive care patients. We encourage the creation of multi-institutional communities to work collaboratively to advance patient safety in high-risk environments like the intensive care unit.