Adverse event reporting in adult intensive care units and the impact of a multifaceted intervention on drug-related adverse events

A retrospective analysis of adverse events reported by Tunisian intensive care units' professionals

INTRODUCTION

Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system.

METHODS

We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021.

RESULTS

A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2).

CONCLUSIONS

The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.

Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units

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.

Interventions to Minimize Medication Error by Nurses in Intensive Care: A Scoping Review Protocol

Medication errors represent a concern for healthcare organizations due to their negative consequences. In the nursing context, these errors represent a threat to the quality of care and patient safety. Many factors have been identified as potential causes for these errors in intensive care units. A scoping review will be developed to identify interventions/strategies to minimize the occurrence of medication errors by nurses, considering the Joanna Briggs Institute (JBI) methodology. A search will be conducted in the EbscoHost (CINAHL Complete and MEDLINE), Embase and PubMed databases. Data analysis, extraction and synthesis will be carried out by two reviewers independently. This review will attempt to map which interventions are more specific to minimizing medication error by nurses in intensive care and to recognize which factors influence this type of error to mitigate practices that may lead to error. This protocol acts as the framework for a scoping review in the strategy to map the interventions and which factors contribute to the medication error by intensive care nurses. This study was prospectively registered with the Open Science Framework on 21 April 2023 with registration number DOI 10.17605/OSF.IO/94KH3.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

An Intervention to Optimize Attitudes Toward Adverse Events Reporting Among Tunisian Critical Care Nurses

OBJECTIVE

This study aimed at evaluating the impact of a combined-strategies intervention on ICUs nurses' attitudes toward AE reporting.

METHODS

We conducted a quasi-experimental study from January to October 2020 which consisted of an intervention to improve attitudes toward incident reporting among nurses working in 10 intensive care units at a university hospital using the Reporting of Clinical Adverse Events Scale. The intervention consisted of a 2-hour educational presentation for nurse unit managers and a 30-minute in-units educational training for intensive care unit nurses, which encompassed technical aspects of reporting, the reporting process, a nonpunitive environment, and the importance of submitting reports. The educational presentation was reinforced with distributing posters and brochures and biweekly patient safety rounds that inquired about events, reinforced education, and provided follow-up to incident reports.

RESULTS

All dimensions were significantly improved. Score increased from 27.4% to 42.1% ( P < 0.01) for perceived blame, from 35.2% to 52.5% for perceived criteria for identifying events that should be reported ( P < 0.01), from 34.3% to 46% for perceptions of colleagues' expectations ( P = 0.04), from 37.1% to 51.4% for perceived benefits of reporting ( P = 0.01), and from 29.2% to 51.4% for perceived clarity of reporting procedures ( P < 0.01).

CONCLUSIONS

Interventions using a combination of several strategies such as training, safety round, and messaging can be effective and should be considered by hospitals attempting to increase adverse events reporting. Results reinforce the assumption that a nonpunitive environment and the resulting feeling of safety and reassurance are crucial to foster the submission of reports.

Increased Mortality and Costs Associated with Adverse Events in Intensive Care Unit Patients

Background: Adverse events (AEs) are defined as unintended complications occurring to patients as a result of medical care. AEs are especially prevalent in the intensive care unit (ICU) setting and may lead to negative patient outcomes. Although many studies have examined the impact of AEs on patient outcomes, few have investigated their associated costs. Methods: The study population consisted of 17 173 adult patients (≥18 years of age) who were admitted to the ICU at The Ottawa Hospital (TOH) between 2011 and 2016. AEs were categorized using an established International Classification of Diseases 10th revision (ICD-10) patient safety indicators (PSI) system for AE detection. Logistic regression was performed to determine the association between AEs and in-hospital outcomes, including mortality. In addition, we constructed a generalized linear model to assess the independent association between AEs and total hospital costs. Results: Patients who experienced an AE had longer total hospital and ICU lengths of stay, required more invasive ICU interventions, had more complex discharge plans, and experienced higher rates of in-hospital mortality compared to those who did not experience an AE. Average total hospital costs and ICU-specific costs were higher among patients who experienced an AE ($72 718; $46 715) relative to their counterparts ($20 543; $16 217), but the per day cost was comparable in both groups. After controlling for age, sex, patient comorbidities, and illness severity, AEs were significantly associated with an increased odds of mortality (OR = 1.13, 95% CIs = 1.04, 1.22) and total average costs (Cost Ratio = 1.04, 95% CIs = 1.06, 1.08). The most impactful AE subtypes from a cost- and patient-perspective were hospital-acquired infections (HAI) and cardiac-related AEs. Conclusion: Incidence of AEs among ICU patients is associated with higher patient mortality and elevated costs. Specific causes of these AEs should be investigated, with further protocols and interventions developed to reduce their occurrence.

Characterization of Medication Errors in a Medical Intensive Care Unit of a University Teaching Hospital in South Korea

OBJECTIVES

The objective of this study was to characterize the current status of medication errors (MEs) throughout the medication therapy process from prescribing to use and monitoring in a medical intensive care unit (MICU) in Korea.

METHODS

Four trained research pharmacists collected data through retrospectively reviewing electronic medical records for adults hospitalized in the MICU in 2017. The occurrence of MEs was determined through interprofessional team discussion led by an academic faculty pharmacist and a medical intensivist based on the medication administration records (MARs). The type of MEs and the consequent ME-related outcome severity were categorized according to the Pharmaceutical Care Network Europe and the National Coordinating Council for Medication Error Reporting and Prevention, respectively.

RESULTS

Overall, electronic medical records for 293 patients with 78,761 MARs were reviewed in this study. At least one type of ME occurred in 271 patients (92.5%) in association with 16,203 MARs (21%), primarily caused by inappropriate dose (35.5%), drug (27.8%), and treatment duration (25.1%). Clinically significant harmful events occurred in 24 patients (8%), including life-threatening (n = 5) and death (n = 2) cases. The 2 patients died of enoxaparin-induced fatal hemorrhage and neutropenia associated with ganciclovir and cefepime. Antibiotics were the most common culprit medications leading to clinically significant harmful events.

CONCLUSIONS

In conclusion, MEs are prevalent in the MICU in Korea, most commonly prescribing errors. Although mostly benign, harmful events including deaths may occur due to MEs, mainly associated with antibiotics. Systematic strategies to minimize these potentially fatal MEs are urgently needed.

Epidemiology of Adverse Events and Medical Errors in the Care of Cardiology Patients

Supplemental digital content is available in the text.

There have been epidemiological studies of adverse events (AEs) among general patients but those of patients cared by cardiologist are not well scrutinized. We investigated the occurrence of AEs and medical errors (MEs) among adult patients with cardiology in Japan.

Adverse Events Among Hospitalized Critically Ill Patients: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to estimate the frequency and type of adverse events (AEs) among critically ill patients and identify patient and hospital factors associated with AEs and clinical and health care utilization consequences of AEs.

MATERIALS AND METHODS

This retrospective cohort study includes patients admitted to 30 intensive care units (ICUs) in Alberta, Canada from May 2014 to April 2017. The main outcome was AEs derived from validated ICD-10, Canadian code algorithms for 18 AEs. Estimates of the proportion and rate of AEs are presented. The association between documented AEs and patient (eg, age, sex, comorbidities) and hospital (eg, ICU site and type, length of stay, readmission) variables are described using regression methods.

RESULTS

Of 49,447 hospital admissions with admission to ICU, ≥1 AEs were documented in 12,549 (25%) admissions. The most common AEs were respiratory complications (10%) and hospital-acquired infections (9%). AEs were associated with having ≥2 comorbidities [odds ratio (OR)=1.4, 95% confidence interval (CI)=1.3-1.4], being admitted to the ICU from the operating room or another hospital ward (OR=1.8, 95% CI=1.7-2.0 and OR=2.7, 95% CI=2.5-3.0, respectively) and being readmitted to ICU during their hospital stay (OR=4.8, 95% CI=4.7-5.6). Patients with an AE stayed 5.4 days longer in ICU (95% CI=5.2-5.6 d, P<0.001), 18.2 days longer in hospital (95% CI=17.7-18.8 d, P<0.001) and had increased odds of hospital mortality (OR=1.5, 95% CI=1.4-1.6) than those without an AE.

CONCLUSIONS

AEs are common among critically ill patients and certain factors are associated with AEs. Documented AEs are associated with longer stays and increased mortality.

Temporal Pattern Detection to Predict Adverse Events in Critical Care: Case Study With Acute Kidney Injury

BACKGROUND

More than 20% of patients admitted to the intensive care unit (ICU) develop an adverse event (AE). No previous study has leveraged patients' data to extract the temporal features using their structural temporal patterns, that is, trends.

OBJECTIVE

This study aimed to improve AE prediction methods by using structural temporal pattern detection that captures global and local temporal trends and to demonstrate these improvements in the detection of acute kidney injury (AKI).

METHODS

Using the Medical Information Mart for Intensive Care dataset, containing 22,542 patients, we extracted both global and local trends using structural pattern detection methods to predict AKI (ie, binary prediction). Classifiers were built on 17 input features consisting of vital signs and laboratory test results using state-of-the-art models; the optimal classifier was selected for comparisons with previous approaches. The classifier with structural pattern detection features was compared with two baseline classifiers that used different temporal feature extraction approaches commonly used in the literature: (1) symbolic temporal pattern detection, which is the most common approach for multivariate time series classification; and (2) the last recorded value before the prediction point, which is the most common approach to extract temporal data in the AKI prediction literature. Moreover, we assessed the individual contribution of global and local trends. Classifier performance was measured in terms of accuracy (primary outcome), area under the curve, and F-measure. For all experiments, we employed 20-fold cross-validation.

RESULTS

Random forest was the best classifier using structural temporal pattern detection. The accuracy of the classifier with local and global trend features was significantly higher than that while using symbolic temporal pattern detection and the last recorded value (81.3% vs 70.6% vs 58.1%; P<.001). Excluding local or global features reduced the accuracy to 74.4% or 78.1%, respectively (P<.001).

CONCLUSIONS

Classifiers using features obtained from structural temporal pattern detection significantly improved the prediction of AKI onset in ICU patients over two baselines based on common previous approaches. The proposed method is a generalizable approach to predict AEs in critical care that may be used to help clinicians intervene in a timely manner to prevent or mitigate AEs.

Medication safety in a German telemedicine centre: Implementation of a telepharmaceutical expert consultation in addition to existing tele-intensive care unit services

Introduction

Tele-intensive care unit (tele-ICU) services offer the possibility to provide specialized medical care in remote areas and to improve patient outcomes. The aim of this study was to implement and evaluate an additional telepharmaceutical expert consultation as part of tele-ICU services.

Methods

This is a prospective observational study conducted in the telemedicine centre of the University Hospital RWTH Aachen, Germany. Between March and July 2015, all tele-ICU patients of one internal and two remote ICUs received telepharmaceutical consultation. Number and type of drug related problems (DRPs) were identified in a comprehensive medication safety check. Implementation of DRPs was discussed interdisciplinarily by tele-ICU pharmacist, tele-ICU physician and remote ICU physician. Special focus was on drug–drug interactions (DDIs) and dosage adjustment in renal and liver failure.

Results

A total of 210 DRPs in 103 patients were identified and discussed. On average, 2.0 (range 0–17) DRPs per patient were found. At least one DRP was found in 62% of patients. Antibacterials for systemic use were most involved in DRPs. A total of 1129 DDI-alerts were generated by ID PHARMA CHECK®. Fifty-six DDIs (5%) were discussed in tele-ICU rounds. The tele-ICU team discussed 28 cases of dosage adjustment in organ failure.

Discussion

Telepharmaceutical consultation as part of tele-ICU services was successfully implemented and can improve medication safety. Telemedicine infrastructure provides the possibility to implement guidelines recommending pharmaceutical service in the ICU in remote hospitals not having access to clinical pharmacists. Thus, quality of care can be improved.

Nature of nursing errors and their contributing factors in intensive care units

BACKGROUND

Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety.

AIM

To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs).

METHODS

A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis.

RESULTS

A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient.

CONCLUSIONS

Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness.

RELEVANCE TO CLINICAL PRACTICE

Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety.

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation

BACKGROUND

Medication errors are the most common type of medical errors critical care patients experience. Critical care units utilise a variety of resources to reduce medication errors; it is unknown which resources or combinations thereof are most effective in improving medication safety.

OBJECTIVES

To obtain UK critical care pharmacist group consensus on the most important interventions/resources that reduce medication errors. To then classify units that participated in the PROTECTED UK study to investigate if there were significant differences in the reported pharmacist prescription intervention type, clinical impact and rates according to unit resource classification.

METHODS

An e-Delphi process (three rounds) obtained pharmacist consensus on which interventions/resources were most important in the reduction of medication errors in critical care patients. The 21 units involved in the PROTECTED UK study (multicentre study of UK critical care pharmacist medicines interventions), were categorised as high-, medium- and low-resource units based on routine delivery of the final Top 5 interventions/ resources. High and low units were compared according to type, clinical impact and rate of medication interventions reported during the PROTECTED UK study.

KEY FINDINGS

Consensus on the Top 5 combined medication error reduction resources was established: advanced-level clinical pharmacist embedded in critical care being ranked most important. Pharmacists working on units with high resources made significantly more clinically significant medicines optimisations compared to those on low-resourced units (OR 3.09; P = 0.035).

CONCLUSIONS

Critical care pharmacist group consensus on the most important medication error reduction resources was established. Pharmacists working on high-resourced units made more clinically significant medicines optimisations.

Análise de eventos adversos em pacientes internados em unidade de terapia intensiva

Resumo Objetivo Avaliar a incidência de eventos adversos e associá-los com a carga de trabalho de enfermagem, o dimensionamento da equipe de enfermagem e o perfil de gravidade do paciente. Métodos Foi realizado um estudo transversal, prospectivo, com abordagem quantitativa, em 304 pacientes consecutivos internados em Unidade de Terapia Intensiva geral de um hospital privado, admitidos entre setembro e dezembro de 2013 (quatro meses). Resultados Ocorreram 39 eventos adversos sendo a lesão por pressão a mais prevalente. Os pacientes que apresentaram algum evento tiveram maior média de idade, maior prevalência de internações clínicas, internações mais prolongadas, maior escala Acute Physiology and Chronic Health Evaluation (APACHE) II, maior pontuação do Nursing Activities Score (NAS), menor escore na escala de Braden e menor escala de Glasgow e não tiveram diferenças significantes em relação ao dimensionamento da equipe de enfermagem. Conclusão Houve maior incidência de eventos adversos em pacientes que exibiram um perfil de maior risco e gravidade identificados por meio de escalas preditoras.

Fatores associados aos incidentes de segurança entre idosos em terapia intensiva

Resumo Objetivo Verificar os fatores demográficos e clínicos associados aos incidentes de segurança entre idosos em terapia intensiva. Métodos Estudo retrospectivo em prontuários de 112 admissões de idosos internados na Unidade de Terapia Intensiva em 2015. Os dados foram coletados de janeiro a junho de 2016, utilizando: Formulário de caracterização da população, Simplified Acute Physiology Score II; índice de Charlson e a Classificação Internacional de Segurança do Paciente; analisados por regressão linear múltipla (p<0,05). Resultados O tempo de internação aumentou todos os tipos de incidentes sem dano (ISD), eventos adversos (EA) geral, processo/procedimento e infecção. O sexo masculino aumentou os ISD de dieta e, o feminino, EA de administração. O grupo etário de 60 a 79 anos aumentou ISD de medicação. A internação clínica aumentou os ISD de comportamento e, a cirúrgica, EA de infecção. Conclusão Tempo de internação; sexo, grupo etário e internação associaram-se ao aumento de ISD e EA.

Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study

This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence. Resumo: Este estudo teve como objetivo avaliar a ocorrência de eventos adversos e o impacto deles sobre o tempo de permanência e a mortalidade na unidade de terapia intensiva (UTI). Trata-se de um estudo prospectivo desenvolvido em um hospital de ensino do Rio de Janeiro, Brasil. A coorte foi formada por 355 pacientes maiores de 18 anos, admitidos na UTI, no período de 1º de agosto de 2011 a 31 de julho de 2012. O processo de identificação de eventos adversos baseou-se em uma adaptação do método proposto pelo Institute for Healthcare Improvement. A regressão logística foi utilizada para analisar a associação entre a ocorrência de evento adverso e o óbito, ajustado pela gravidade do paciente. Confirmados 324 eventos adversos em 115 pacientes internados ao longo de um ano de seguimento. A taxa de incidência foi de 9,3 eventos adversos por 100 pacientes-dia, e a ocorrência de evento adverso impactou no aumento do tempo de internação (19 dias) e na mortalidade (OR = 2,047; IC95%: 1,172-3,570). Este estudo destaca o sério problema dos eventos adversos na assistência à saúde prestada na terapia intensiva e os fatores de risco associados à incidência de eventos.

[Analysis of an incident notification system and register in a critical care unit]

OBJECTIVE

To analyse the incident communicated through a notification system and register in a critical care unit.

METHODOLOGY

A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma.

STUDY VARIABLES

incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables.

RESULTS

Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%.

CONCLUSIONS

Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication.

An integrative review of drug errors in critical care

Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

The incidence of adverse events in an Italian acute care hospital: findings of a two-stage method in a retrospective cohort study

Background

The promotion of safer healthcare interventions in hospitals is a relevant public health topic. This study is aimed to investigate predictors of Adverse Events (AEs) taking into consideration the Charlson Index in order to control for confounding biases related to comorbidity.

Methods

The study was a retrospective cohort study based on a two-stage assessment tool which was used to identify AEs. In stage 1, two physicians reviewed a random sample of patient records from 2008 discharges. In stage 2, reviewers independently assessed each screened record to confirm the presence of AEs. A univariable and multivariable analysis was conducted to identify prognostic factors of AEs; socio-demographic and some main organizational variables were taken into consideration. Charlson comorbidity Index was calculated using the algorithm developed by Quan et al.

Results

A total of 1501 records were reviewed; mean patients age was 60 (SD: 19) and 1415 (94.3%) patients were Italian. Forty-six (3.3%) AEs were registered; they most took place in medical wards (33, 71.7%), followed by surgical ones (9, 19.6%) and intensive care unit (ICU) (4, 8.7%). According to the logistic regression model and controlling for Charlson Index, the following variables were associated to AEs: type of admission (emergency vs elective: OR 3.47, 95% CI: 1.60-7.53), discharge ward (surgical and ICU vs medical wards: OR 2.29, 95% CI: 1.00-5.21 and OR 4.80, 95% CI: 1.47-15.66 respectively) and length of stay (OR 1.03, 95% CI 1.01-1.04). Among patients experiencing AEs a higher frequency of elderly (≥65 years) was shown (58.7% vs 49.3% among patients without AEs) but this difference was not statistically significant. Interestingly, a higher percentage of patients admitted through emergency department was found among patients experiencing AEs (69.7% vs 55.1% among patients without AEs).

Conclusions

The incidence of AEs was associated with length of stay, type of admission and unit of discharge, independently by comorbidity. On the basis of our results, it appears that organizational characteristics, taking into account the adjustment for comorbidity, are the main factors responsible for AEs while patient vulnerability played a minor role.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-358) contains supplementary material, which is available to authorized users.

Approaches to decreasing medication and other care errors in the ICU

PURPOSE OF REVIEW

The very complex process of intensive care is accompanied by a not unexpected accumulation of risk for error and adverse events. The present review addresses strategies to decrease care errors in several domains of daily intensive care practice.

RECENT FINDINGS

Strategies to decrease care errors now focus on a systematic approach by identifying latent system failures and change the design of the care process in such a way that inevitable human errors are prevented or their consequences are mitigated. Recent examples refer to the standardization of processes, adaptation to cognitive limitations of human beings, optimization of working conditions, and the increasing use of supporting information technologies. The development of a safety climate constitutes a key element and apparently contributes to reduction of medical errors in ICUs.

SUMMARY

The present review discusses recent approaches aimed to decrease care errors in ICUs. A growing body of evidence demonstrates that a system based approach with the change of process characteristics and the development of a safety climate is most essential in the effort to increase patient safety.