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Abstract

Introduction: Learning from near misses (NMs) may reduce the incidence of preventable errors. Current literature on NMs in the ICU focuses on errors reported by nurses and intensivists. Hypothesis: ICU NMs identified by anesthesia providers will reveal critical events, causal mechanisms and system weaknesses not identified by other providers. ICU NMs may differ in character and causality from NMs in other anesthesia locations. Methods: We analyzed events reported to our NM system from 2009-11. Each report contains a free text description of the event, its location in the hospital (OR, PACU/pre-op, L&D, remote location, or ICU), time of day (day vs. night/weekend), and causative mechanisms based on the JCAHO patient safety event taxonomy. We classified NMs as systems errors and technical/equipment errors based on the JCAHO taxonomy, and identified NMs associated with airway management based on the free text description. We compared causative mechanisms of ICU NMs with NMs in other locations. Results: 2485 NMs were reported, of which 47 (1.89%) were in the ICU. Four causal mechanisms explained over half of ICU NMs: failure to execute a skill appropriately (17%), failure to perform a routine task (15%), poor safety culture (10%), and equipment malfunction (10%). Compared with NMs in other locations, ICU NMs were more likely to occur while on-call (47% vs. 19%, respectively, p < 0.001), and more likely to be associated with airway management (49% vs. 13%, p < 0.001). ICU and non-ICU NMs were equally likely to be associated with human rather than systems errors (36% vs. 37%, p = 0.89), technical/equipment error (33% vs. 41%, p = 0.24), or a poor safety culture (11% vs. 9%, p = 0.74). Compared specifically to PACU/pre-op NMs, ICU NMs were more likely to be associated with a technical/equipment error (11% vs. 33%, p = 0.002). Conclusions: To our knowledge, this is the first analysis of NMs associated with ICU care from the perspective of the anesthesia provider. A few causal mechanisms explained most ICU NMs, providing targets for quality improvement. Errors associated with airway management may be more common in the ICU than other anesthesia locations, and inadequate or malfunctioning equipment may play a role.