Abstract
BackgroundLearning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations.MethodsWe analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations.ResultsA total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02).ConclusionsA limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
Highlights
Learning from adverse events and near misses may reduce the incidence of preventable errors
This study focused on near misses reported by anesthesia providers in the intensive care unit (ICU) over a three-year period
Since our data were collected from a single academic anesthesia department with a large number of critical care trained faculty, our findings may not be generalizable to other institutions. To our knowledge, this is the first analysis of near miss reports associated with ICU care from the perspective of the anesthesia provider
Summary
Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. Errors occur more frequently in the intensive care unit (ICU) than other areas of the hospital due to the acuity of illness and the frequency and complexity of interventions [2]. Incident reporting systems and protocols for the analysis of patient safety events are essential components of ICU patient safety programs, [3] since learning from adverse events may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU primarily relies on events reported by critical care nurses and intensivist physicians [4,5,6,7,8,9]. No study has focused solely on patient safety events in the ICU from the unique perspective of the anesthesiologist
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