Thomas AN, MacDonald JJ. A review of patient safety incidents reported as 'severe' or 'death' from critical care units in England and Wales between 2004 and 2014.
Anaesthesia 2016;
71:1013-23. [PMID:
27456207 DOI:
10.1111/anae.13547]
[Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 12/11/2022]
Abstract
We analysed 1743 patient safety incidents reported between 2004 and 2014 from critical care units in England and Wales where the harm had been classified as 'severe' (1346, 77%) or 'death' (397, 23%). We classified 593 (34%) of these incidents as resulting in temporary harm, and 782 (45%) as more than temporary harm, of which 389 (22%) may have contributed to the patient's death. We found no described harm in 368 (21%) incidents. We classified 1555 (89%) of the incidents as being avoidable or potentially avoidable. There were changes over time for some incident types (pressure sores: 10 incidents in 2007, 64 in 2012; infections: 60 incidents in 2007, 10 in 2012) and some changes in response to national guidance. We made a comparison with a dataset of all incidents reported from units in North-West England, and this confirmed that the search strategy identified more severe incidents, but did not identify all incidents that contributed to mortality.
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