Patient Safety in Intensive Care: Results from the Multinational Sentinel Events Evaluation (SEE) Study

Overview

Journal Intensive Care Med

Specialty Critical Care

Date 2006 Jul 29

PMID 16874492

Citations 55

Authors

Andreas Valentin

Maurizia Capuzzo

Bertrand Guidet

Rui P Moreno

Lorenz Dolanski

Peter Bauer

Philipp G H Metnitz

Affiliations

Soon will be listed here.

Abstract

Objective: To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs).

Design: An observational, 24-h cross-sectional study of incidents in five representative categories.

Setting: 205 ICUs worldwide

Measurements: Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.

Results: In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7-42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00-1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18-2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04-1.08).

Conclusions: Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.

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References

Vincent C, Neale G, Woloshynowych M . Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001; 322(7285):517-9. PMC: 26554. DOI: 10.1136/bmj.322.7285.517. View

Chang A, Schyve P, Croteau R, OLeary D, Loeb J . The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care. 2005; 17(2):95-105. DOI: 10.1093/intqhc/mzi021. View

Altman D, Clancy C, Blendon R . Improving patient safety--five years after the IOM report. N Engl J Med. 2004; 351(20):2041-3. DOI: 10.1056/NEJMp048243. View

Vincent C, Stanhope N . Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999; 5(1):13-21. DOI: 10.1046/j.1365-2753.1999.00147.x. View

Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J . The Quality in Australian Health Care Study. Med J Aust. 1995; 163(9):458-71. DOI: 10.5694/j.1326-5377.1995.tb124691.x. View

Needham D, Thompson D, Holzmueller C, Dorman T, Lubomski L, Wu A . A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2005; 32(11):2227-33. DOI: 10.1097/01.ccm.0000145230.52725.6c. View

Osmon S, Harris C, Dunagan W, Prentice D, Fraser V, Kollef M . Reporting of medical errors: an intensive care unit experience. Crit Care Med. 2004; 32(3):727-33. DOI: 10.1097/01.ccm.0000114822.36890.7c. View

Parshuram C, Ng G, Ho T, Klein J, Moore A, Bohn D . Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med. 2003; 31(10):2483-7. DOI: 10.1097/01.CCM.0000089638.83803.B2. View

Dodek P, Raboud J . Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 2003; 29(9):1584-8. DOI: 10.1007/s00134-003-1815-y. View

10.

Stanhope N, Vincent C, OConnor A . An evaluation of adverse incident reporting. J Eval Clin Pract. 1999; 5(1):5-12. DOI: 10.1046/j.1365-2753.1999.00146.x. View

11.

Wasserfallen J, Butschi A, Muff P, Biollaz J, Schaller M, Pannatier A . Format of medical order sheet improves security of antibiotics prescription: The experience of an intensive care unit. Crit Care Med. 2004; 32(3):655-9. DOI: 10.1097/01.ccm.0000114835.97789.ab. View

12.

Landrigan C, Rothschild J, Cronin J, Kaushal R, Burdick E, Katz J . Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351(18):1838-48. DOI: 10.1056/NEJMoa041406. View

13.

Epstein S, Nevins M, Chung J . Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med. 2000; 161(6):1912-6. DOI: 10.1164/ajrccm.161.6.9908068. View

14.

Schioler T, Lipczak H, Pedersen B, Mogensen T, Bech K, Stockmarr A . [Incidence of adverse events in hospitals. A retrospective study of medical records]. Ugeskr Laeger. 2001; 163(39):5370-8. View

15.

Needham D, Sinopoli D, Thompson D, Holzmueller C, Dorman T, Lubomski L . A system factors analysis of "line, tube, and drain" incidents in the intensive care unit. Crit Care Med. 2005; 33(8):1701-7. DOI: 10.1097/01.ccm.0000171205.73728.81. View

16.

Flaatten H, Hevroy O . Errors in the intensive care unit (ICU). Experiences with an anonymous registration. Acta Anaesthesiol Scand. 1999; 43(6):614-7. DOI: 10.1034/j.1399-6576.1999.430604.x. View

17.

Herout P, Erstad B . Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med. 2004; 32(2):428-32. DOI: 10.1097/01.CCM.0000108876.12846.B7. View

18.

Bracco D, Favre J, Bissonnette B, Wasserfallen J, Revelly J, Ravussin P . Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med. 2001; 27(1):137-45. DOI: 10.1007/s001340000751. View

19.

Beckmann U, Baldwin I, Hart G, Runciman W . The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesth Intensive Care. 1996; 24(3):320-9. DOI: 10.1177/0310057X9602400304. View

20.

Pronovost P, Wu A, Sexton J . Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004; 140(12):1025-33. DOI: 10.7326/0003-4819-140-12-200406150-00013. View