A prospective study of patient safety in the operating room.

A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units

Objective To assess on a multinational level the frequency, characteristics, contributing factors, and preventive measures of administration errors in parenteral medication in intensive care units. Design Observational, prospective, 24 hour cross sectional study with self reporting by staff. Setting 113 intensive care units in 27 countries. Participants 1328 adults in intensive care. Main outcome measures Number of errors; impact of errors; distribution of error characteristics; distribution of contributing and preventive factors. Results 861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage. In a multiple logistic regression with patients as the unit of analysis, odds ratios for the occurrence of at least one parenteral medication error were raised for number of organ failures (odds ratio per increase of one organ failure: 1.19, 95% confidence interval 1.05 to 1.34); use of any intravenous medication (yes v no: 2.73, 1.39 to 5.36); number of parenteral administrations (per increase of one parenteral administration: 1.06, 1.04 to 1.08); typical interventions in patients in intensive care (yes v no: 1.50, 1.14 to 1.96); larger intensive care unit (per increase of one bed: 1.01, 1.00 to 1.02); number of patients per nurse (per increase of one patient: 1.30, 1.03 to 1.64); and occupancy rate (per 10% increase: 1.03, 1.00 to 1.05). Odds ratios for the occurrence of parenteral medication errors were decreased for presence of basic monitoring (yes v no: 0.19, 0.07 to 0.49); an existing critical incident reporting system (yes v no: 0.69, 0.53 to 0.90); an established routine of checks at nurses’ shift change (yes v no: 0.68, 0.52 to 0.90); and an increased ratio of patient turnover to the size of the unit (per increase of one patient: 0.73, 0.57 to 0.93). Conclusions Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.

https://www.bmj.com/content/bmj/338/bmj.b814.full.pdf

Errors in administration of parenteral drugs in intensive care units: multinational prospective study

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). An observational, 24-h cross-sectional study of incidents in five representative categories. 205 ICUs worldwide Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed. 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). 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.

/pdf/patient-safety-in-intensive-care-results-from-the-1fbrlhihwi.pdf

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study

In high-risk industries such as aviation, the skills not related directly to technical expertise, but crucial for maintaining safety (e.g. teamwork), have been categorized as non-technical skills. Recently, research in anaesthesia has identified and developed a taxonomy of the non-technical skills requisite for safety in the operating theatre. Although many of the principles related to performance and safety within anaesthesia are relevant to the intensive care unit (ICU), relatively little research has been done to identify the non-technical skills required for safe practice within the ICU. This review focused upon critical incident studies in the ICU, in order to examine whether the contributory factors identified as underlying the critical incidents, were associated with the skill categories (e.g. task management, teamwork, situation awareness and decision making) outlined in the Anaesthetists' Non-technical Skills (ANTS) taxonomy. We found that a large proportion of the contributory factors underlying critical incidents could be attributed to a non-technical skill category outlined in the ANTS taxonomy. This is informative both for future critical incident reporting, and also as an indication that the ANTS taxonomy may provide a good starting point for the development of a non-technical skills taxonomy for intensive care. However, the ICU presents a range of unique challenges to practitioners working within it. It is therefore necessary to conduct further non-technical skills research, using human factors techniques such as root-cause analyses, observation of behaviour, attitudinal surveys, studies of cognition, and structured interviews to develop a better understanding of the non-technical skills important for safety within the ICU. Examples of such research highlight the utility of these techniques.

Non-Technical Skills in the Intensive Care Unit: A review of the current literature

Objectives: To determine the incidence and identify risk factors of critical incidents in an ICU. Design: Prospective observational study of consecutive patients admitted over 1 year to an ICU. Critical incidents were recorded using predefined criteria. Their causes and consequences were analysed. The causes were classified as technical failure, patient's underlying disease, or human errors (subclassified as planning, execution, or surveillance). The consequences were classified as lethal, leading to sequelae, prolonging the ICU stay, minor, or without consequences. The correlation between critical incidents and specific factors including patient's diagnosis and severity score, use of monitoring and therapeutic modalities was analysed by uni- and multivariate analysis. Setting: An 11-bed multidisciplinary ICU in a non-university teaching hospital. Patients: 1024 consecutive patients admitted to the ICU. Intervention: None. Measurementsandmainresults: The median length of ICU stay by the 1024 patients was 1.9 days. Of the 777 critical incidents reported 2% were due to technical failure and 67% to secondary to underlying disease. There were 241 human errors (31%) in 161 patients, evenly distributed among planning (n=75), execution (n=88), and surveillance (n=78). One error was lethal, two led to sequelae, 26% prolonged ICU stay, and 57% were minor and 16% without consequence. Errors with significant consequences were related mainly to planning. Human errors prolonged ICU stay by 425 patient-days, amounting to 15% of ICU time. Readmitted patients had more frequent and more severe critical incidents than primarily admitted patients. Conclusions: Critical incidents add morbidity, workload, and financial burden. A substantial proportion of them are related to human factors with dire consequences. Efforts must focus on timely, appropriate care to avoid planning and execution mishaps at the beginning of the ICU stay; surveillance intensity must be maintained, specially after the fourth day.

Jean-Baptiste Favre

Papers

Human errors in a multidisciplinary intensive care unit: a 1-year prospective study

Pulmonary Injury After Ski Wax Inhalation Exposure