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Obayashi M, Shimoyama K, Ono K. Impact of Collaborative Nursing Care Delivery on Patient Safety Events in an Emergency Intensive Care Unit: A Retrospective Observational Study. J Patient Saf 2024; 20:252-258. [PMID: 38446064 DOI: 10.1097/pts.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
OBJECTIVES Patient safety events (PSEs) have detrimental consequences for patients and healthcare staff, highlighting the importance of prevention. Although evidence shows that nurse staffing affects PSEs, the role of an appropriate nursing care delivery system remains unclear. The current study aimed to investigate whether nursing care delivery systems could prevent PSEs. METHODS This retrospective study was conducted in Japan. The study examined the collaborative 4:2 nursing care delivery system in which 2 nurses are assigned to care for 4 patients, collaborating to perform tasks, and provide care. The cohort receiving care from a collaborative 4:2 nursing care delivery system was labeled the postintervention, whereas the cohort receiving care from a conventional individualized system, in which one nurse provides care for 2 patients, was labeled the preintervention. The primary outcome was the occurrence of PSEs. RESULTS The preintervention and postintervention comprised 561 and 401 patients, respectively, with the latter consisting of a younger and more critically ill population. The number of PSEs per 1000 patient-days was not significantly different between the 2 groups (10.3 [95% confidence interval, 7.1-13.5] versus 6.0 [95% confidence interval, 3.2-8.9], P = 0.058). Multiple logistic regression analysis showed that the collaborative 4:2 nursing care delivery system was significantly associated with PSEs (adjusted odds ratio, 0.53; 95% confidence interval, 0.29-0.95; P = 0.037). CONCLUSIONS These findings suggest that in an emergency intensive care unit, a collaborative nursing care delivery system was associated with a decrease in PSEs.
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Affiliation(s)
- Masato Obayashi
- From the Division of Emergency Intensive Care Unit, Tokyo Medical University Hospital
| | - Keiichiro Shimoyama
- Department of Emergency and Critical Care Medicine, Tokyo Medical University
| | - Koji Ono
- Postgraduate School of Nursing, Postgraduate School, Tokyo Healthcare University, Tokyo, Japan
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Griffeth EM, Gajic O, Schueler N, Todd A, Ramar K. Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units. J Patient Saf 2023; 19:422-428. [PMID: 37466643 PMCID: PMC10526728 DOI: 10.1097/pts.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Patient safety incident reporting in our institution's intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. METHODS Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February-April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. RESULTS Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [ P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline ( P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. CONCLUSIONS This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.
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Affiliation(s)
- Elaine M. Griffeth
- Department of Surgery; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Nicole Schueler
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Austin Todd
- Department of Quantitative Health Sciences Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
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Seino Y, Sato N, Idei M, Nomura T. The Reduction in Medical Errors on Implementing an Intensive Care Information System in a Setting Where a Hospital Electronic Medical Record System is Already in Use: Retrospective Analysis. JMIR Perioper Med 2022; 5:e39782. [PMID: 35964333 PMCID: PMC9475405 DOI: 10.2196/39782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear. Objective This study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use. Methods An ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined. Results From April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error. Conclusions ICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345
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Affiliation(s)
- Yusuke Seino
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuo Sato
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Idei
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
- Department of Anesthesiology and Intensive Care Medicine, Yokohama City University, Yokohama, Japan
| | - Takeshi Nomura
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Juneja D, Mishra A. Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace. Indian J Crit Care Med 2022; 26:541-542. [PMID: 35719448 PMCID: PMC9160622 DOI: 10.5005/jp-journals-10071-24215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Juneja D, Mishra A. Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace. Indian J Crit Care Med 2022;26(5):541–542.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
- Deven Juneja, Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India, Phone: +91 9818290380, e-mail:
| | - Anjali Mishra
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi, India
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Danielis M, Bellomo F, Farneti F, Palese A. Critical incidents rates and types in Italian Intensive Care Units: A five-year analysis. Intensive Crit Care Nurs 2020; 62:102950. [PMID: 33131994 DOI: 10.1016/j.iccn.2020.102950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe rates and types of critical incidents in Intensive Care Units. RESEARCH METHODOLOGY A retrospective study in four intensive care units of an Academic Hospital located in the North-East of Italy. All critical incidents recorded in an incident reporting system database from 2013 to 2017 were collected. RESULTS 160 critical incidents emerged. The rate was 1.7/100 intensive care-patient admissions, and 2.86/1000 in intensive care-patient days. Nurses reported most of the critical incidents (n = 113, 70.6%). In 2013 there were 19 (11.9%) critical incidents which significantly increased by 2017 (n = 38, 23.7%; p = 0.034). The most frequent critical incidents were medication/intravenous fluids issues (n = 35, 21.9%) and resources and organisational management (n = 35, 21.9%). Less frequently occurring incidents concerned medical devices/equipment (n = 29, 18.1%), clinical processes/procedures (n = 18, 11.3%), documentation (n = 14, 8.8%) and patient accidents (n = 13, 8.1%). Rare incidents included behaviour, clinical administration, nutrition, blood products and healthcare associated infection. CONCLUSION Over a five-year period, documented incidents were steadily increasing in four Italian intensive care units. A voluntary incident reporting system might provide precious information on safety issues occurring in units. at both policy and professional levels.
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Affiliation(s)
- Matteo Danielis
- School of Nursing, Department of Medical Sciences, University of Udine, Viale Ungheria 20, 33100 Udine, Italy.
| | - Fabrizio Bellomo
- Accreditation, Clinical Risk Management and Performance Assessment Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Federico Farneti
- Accreditation, Clinical Risk Management and Performance Assessment Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Alvisa Palese
- School of Nursing, Department of Medical Sciences, University of Udine, Viale Ungheria 20, 33100 Udine, Italy
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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Wright J, Lawton R, O’Hara J, Armitage G, Sheard L, Marsh C, Grange A, McEachan RRC, Cocks K, Hrisos S, Thomson R, Jha V, Thorp L, Conway M, Gulab A, Walsh P, Watt I. Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- John Wright
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rebecca Lawton
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jane O’Hara
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Medical Education, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Gerry Armitage
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Laura Sheard
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Marsh
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Angela Grange
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rosemary RC McEachan
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kim Cocks
- York Trials Unit, University of York, York, UK
| | - Susan Hrisos
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Richard Thomson
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Vikram Jha
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Liz Thorp
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Peter Walsh
- Action against Medical Accidents, Croydon, UK
| | - Ian Watt
- Department of Health Sciences, University of York, York, UK
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Brunsveld-Reinders AH, Arbous MS, De Vos R, De Jonge E. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care 2015; 28:2-13. [DOI: 10.1093/intqhc/mzv100] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 01/19/2023] Open
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The effectiveness of an intensive care quick reference checklist manual—A randomized simulation-based trial. J Crit Care 2015; 30:255-60. [DOI: 10.1016/j.jcrc.2014.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/10/2014] [Accepted: 10/06/2014] [Indexed: 11/19/2022]
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Yılmaz KB, Akıncı M, Şeker D, Güller M, Güneri G, Kulaçoğlu H. Factors affecting the safety of drains and catheters in surgical patients. ULUSAL CERRAHI DERGISI 2014; 30:90-2. [PMID: 25931902 DOI: 10.5152/ucd.2014.2564] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 03/02/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Drains and catheters are used for both prophylactic and therapeutic reasons in clinical practice. This study aimed to investigate the factors that affect safety of drains, catheters, nasogastric tube and central venous line in patients who underwent surgery. MATERIAL AND METHODS Two hundred and four consecutive patients who were operated at the general surgery clinics under general anesthesia were included in the study. Factors that affect the safety of drains and catheter were followed and recorded prospectively. RESULTS During follow-up period, 12 (5.8%) patients have experienced problems regarding safety of drains/catheters. The mean age of patients who were followed-up in terms of security problems was 63.1 (39-86) years. Eight (66.7%) patients had been operated emergently, and four (33.3%) patients electively. Three (25%) patients had psychiatric/neurological co-morbidities and 3 (25%) patients were confused due to anesthesia/intensive care unit treatment when the drain safety was broken. Eight (66.7%) patients withdrew the drains or catheters by themselves, in 2 (16.7%) patients the drains spontaneously came out and in 2 (16.7%) patients the wrong drain was withdrawn. One patient had dementia, one patient had Alzheimer's disease and one patient was being followed-up with a diagnosis of schizophrenia. In three (25%) patients the abdominal drain, in four (33.3%) patients nasogastric tube, in one (8.3%) patient intubation tube, in one (8.3%) patient central venous catheter, and in three (25%) patients multiple drains were removed. CONCLUSION The inaccurate use of drains or re-intervention for an unintentionally removed drain causes problems regarding patient safety. Close monitoring of surgical patients in terms of security, and submission of additional measures for patients with confusion and neurological/psychiatric disorders are of great importance.
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Affiliation(s)
- Kerim Bora Yılmaz
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
| | - Melih Akıncı
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
| | - Duray Şeker
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
| | - Müjdat Güller
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
| | - Gürkan Güneri
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
| | - Hakan Kulaçoğlu
- Clinic of General Surgery, Dışkapı Teaching and Training Hospital, Ankara, Turkey
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Elliott M, Page K, Worrall-Carter L. Factors associated with post-intensive care unit adverse events: a clinical validation study. Nurs Crit Care 2014; 19:228-35. [PMID: 24809526 DOI: 10.1111/nicc.12091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 02/02/2014] [Accepted: 02/04/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events. AIM This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice. DESIGN Prospective, clinical validation study. METHOD Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge. RESULTS Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities. CONCLUSION Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients. RELEVANCE TO CLINICAL PRACTICE Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced.
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Affiliation(s)
- Malcolm Elliott
- M Elliott, RN, BN, Doctoral Candidate, St. Vincent's Centre for Nursing Research, Melbourne, Australia
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Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? Curr Opin Crit Care 2013; 16:649-53. [PMID: 20930624 DOI: 10.1097/mcc.0b013e32834044d8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.
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Parmentier-Decrucq E, Poissy J, Favory R, Nseir S, Onimus T, Guerry MJ, Durocher A, Mathieu D. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors. Ann Intensive Care 2013; 3:10. [PMID: 23587445 PMCID: PMC3639083 DOI: 10.1186/2110-5820-3-10] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/07/2013] [Indexed: 01/03/2023] Open
Abstract
Background Transport of critically ill patients for diagnostic or therapeutic procedures is at risk of complications. Adverse events during transport are common and may have significant consequences for the patient. The objective of the study was to collect prospectively adverse events that occurred during intrahospital transports of critically ill patients and to determine their risk factors. Methods This prospective, observational study of intrahospital transport of consecutively admitted patients with mechanical ventilation was conducted in a 38-bed intensive care unit in a university hospital from May 2009 to March 2010. Results Of 262 transports observed (184 patients), 120 (45.8%) were associated with adverse events. Risk factors were ventilation with positive end-expiratory pressure >6 cmH2O, sedation before transport, and fluid loading for intrahospital transports. Within these intrahospital transports with adverse events, 68 (26% of all intrahospital transports) were associated with an adverse event affecting the patient. Identified risk factors were: positive end-expiratory pressure >6 cmH2O, and treatment modification before transport. In 44 cases (16.8% of all intrahospital transports), adverse event was considered serious for the patient. In our study, adverse events did not statistically increase ventilator-associated pneumonia, time spent on mechanical ventilation, or length of stay in the intensive care unit. Conclusions This study confirms that the intrahospital transports of critically ill patients leads to a significant number of adverse events. Although in our study adverse events have not had major consequences on the patient stay, efforts should be made to decrease their incidence.
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Affiliation(s)
- Erika Parmentier-Decrucq
- Service d'Urgence Respiratoire, Réanimation Médicale et Medecine Hyperbare, Université de Lille II et Centre Hospitalier et Universitaire de Lille, Lille 59037, France.
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Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012; 21:369-80. [PMID: 22421911 PMCID: PMC3332004 DOI: 10.1136/bmjqs-2011-000443] [Citation(s) in RCA: 193] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this systematic review was to develop a 'contributory factors framework' from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. DESIGN A mixed-methods systematic review of the literature was conducted. DATA SOURCES Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. ELIGIBILITY CRITERIA Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. RESULTS 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. CONCLUSIONS This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.
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Affiliation(s)
- Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, UK.
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The Nature and Causes of Unintended Events Reported at 10 Internal Medicine Departments. J Patient Saf 2011; 7:224-31. [DOI: 10.1097/pts.0b013e3182388f97] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 2009; 37:2775-81. [DOI: 10.1097/ccm.0b013e3181a96379] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 2009. [DOI: 10.1097/00003246-200910000-00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Calvino Günther S, Schwebel C, Vésin A, Remy J, Dessertaine G, Timsit JF. Interventions to decrease tube, line, and drain removals in intensive care units: the FRATER study. Intensive Care Med 2009; 35:1772-6. [PMID: 19557388 DOI: 10.1007/s00134-009-1555-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 06/04/2009] [Indexed: 11/30/2022]
Abstract
PURPOSES To evaluate the incidence of unintended tube, line, and drain removals (UTRs) in our ICU, to identify system factors associated with UTRs, and to evaluate interventions designed to decrease UTR occurrence. METHODS Interventional study in the 18-bed medical ICU of a French general university hospital. We prospectively determined the incidence and circumstances of UTRs in our ICU over a 2-year period. Demographic and clinical data were collected for consecutively admitted patients, and additional information was recorded about patients experiencing UTRs. Investigators analyzed UTR data twice a month to identify possible causes and developed interventions to decrease UTRs (mainly securing tubes and sedation protocol). Conditional logistic regression stratified on length of stay was used to identify risk factors for UTRs and segmented linear regression analysis to test the effects of interventions. RESULTS Of 2,007 admitted patients (12,256 patient days), 193 (9.6%) experienced 270 UTRs (22/1,000 patient days). Clinical or therapeutic consequences occurred for 17% of UTRs. Three factors were independently associated with UTR; two were risk factors, namely, admission for coma [OR, 2.68; 95% CI (1.87; 3.84); P < 0.0001] and mechanical ventilation in over 65% of all ICU patients [OR = 1.65 (1.19; 2.29); P = 0.003], and one was protective, namely, mean SAPS II >45 in all ICU patients [OR, 0.54; 95% CI (0.39; 0.75); P = 0.0003]. Segmented regression analysis showed a 67.4% drop [95% CI (17.2%; 117.3%); P = 0.009] in the UTR rate after the first intervention was introduced. System factors played a major role in UTR occurrence. CONCLUSION UTRs are common. A continuous quality-improvement program can reduce UTR rates in the ICU.
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Camiré E, Moyen E, Stelfox HT. Medication errors in critical care: risk factors, prevention and disclosure. CMAJ 2009; 180:936-43. [PMID: 19398740 DOI: 10.1503/cmaj.080869] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Eric Camiré
- Department of Critical Care Medicine, University of Calgary, Calgary, Alta
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Affiliation(s)
- Margo A. Halm
- Margo A. Halm is a clinical nurse specialist and director of nursing research and quality at United Hospital in St Paul, Minnesota, where she leads and mentors staff in principles of clinical research and evidence-based practice
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