Major sources of critical incidents in intensive care

Abstract

IntroductionIn recent years, critical incident (CI) reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.MethodsThe study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit (ICU). Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health & safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.ResultsA total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 (30%), clinical practice 257 (22.8%), pharmaceuticals 238 (21.1%), administration 213 (18.9%), health and safety hazards 81 (7.2%). The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.ConclusionsCritical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.

Unplanned extubation in critically ill adults: clinical review

“…High risk for patients admitted to the intensive care unit (ICU) to experience treatment-or procedurerelated incidents has been previously highlighted (Welters et al, 2011). Because of limited cardiorespiratory reserve, critically ill patients may not be able to compensate for additional injury, thus being susceptible to the adverse consequences of critical incidents (Kiekkas et al, 2011).…”

Physiological changes associated with routine nursing procedures in critically ill are common: an observational pilot study

“…In fact, physiological changes associated with nursing procedures are often considered a part of the procedure and have also often been neglected in studies investigating different types of interventions in critically ill patients, even though they could affect the results of such studies. Although adverse events caused by errors in medication and drug administration have been dealt with in several publications, there are few clinical data on the physiological consequences of routine nursing procedures such as patient position change, endotracheal suctioning, clinical examination or care of wounds, and vascular insertion sites . Use of an improved analgesia policy reduced physiological inadvertent changes associated with change of the patient's position from 37% to 17% in one study .…”

Busca ativa contribui na identificação de eventos adversos e incidentes em unidade de terapia intensiva

“…Tales datos se tornan mínimos, cuando comparados de modo aisladamente numérico con otras realidades de Brasil (9,12)y del mundo (13,14) .…”

“…Del mismo modo, otros investigadores identificaron un total de 15.054 eventos/incidentes, siendo este cuantitativo oriundo del análisis de datos en dos hospitales universitarios de alta complejidad, conforme descrito una de las unidades intensivas presenta 910 camas y la otra posee 258 camas (12) . Cuando se verifica que, el análisis prospectiva de ocho meses realizada en UCI de 76 hospitales de España (13) se ha presentado como resultado la ocurrencia de 1.424 eventos/incidentes, se considera que el número de registros de la institución brasileña evaluada en esta investigación se presentó alto, así como cuando comparados con datos de evaluación realizada durante 90 meses en una única UCI con 13 camas de un hospital universitario de Inglaterra (14) .…”