Adverse Incident Reporting in Intensive Care

Abstract

This prospective, observational, anonymous incident reporting study aimed to identify and correct factors leading to reduced patient safety in intensive care. An incident was any event which caused or had the potential to cause harm to the patient, but included problems in policy or procedure. Reports were discussed at monthly meetings. Of 390 incidents, 106 occasioned "actual" harm and 284 "potential" harm. There was one death, 86 severe complications and 88 complications of minor severity. Most were transient but the effects of 24 lasted up to a week. Most incidents affected cardiovascular and respiratory systems. Incident categories involved drugs, equipment, management or procedures. Incident causes were knowledge-based, rule-based, technical, slip/lapse, no error or unclassifiable. The study has identified some human and equipment performance problems in our intensive care unit. Correction of these should lead to a reduction in the future incidence of those events and hence an increased level of patient safety.

Lateral positioning of ventilated intensive care patients: A study of oxygenation, respiratory mechanics, hemodynamics, and adverse events

“…Description of the severity and duration of adverse events were according to Hart et al 25 The study design planned an analysis of physiological data using a linear mixed model analysis (main effects within subjects were group (G), side (S), time (T), and their interaction; subjects were random effects) to analyze outcome measures related to gas exchange, respiratory mechanic, and hemodynamic data. A priori paired-contrasts of T0-T150 were conducted when effects for time were significant.…”

Medication errors in paediatric practice: insights from a continuous quality improvement approach

“…It has been employed in a variety of hospital settings [16,27,30], and was used in the current study because it was likely to be eective, inexpensive and easy to administer [7,24,28]. The main criticism of the technique is the potential for the under-reporting of errors [15]. Studies employing trained observers report a higher incidence of medication errors, particularly administration errors [23,25].…”

Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review*

“…Two widely used methods of quality assessment are incident reporting (2-10) and retrospective medical chart review (MCR) (8,(11)(12)(13)(14)(15)(16)(17)(18).…”