Critical Care Safety Research Articles

A Different View of Health Information Technology Workarounds in Critical Care.

When health information technology (HIT) was introduced into the hospital setting there was an obvious disruption to nursing workflow. In many cases it took a nurse extra steps or extra time to complete processes such as clinical documentation and medication administration. In response to HIT problems, nurses developed workarounds. Research on nursing workarounds has been hindered by a lack of variable definitions, measures and research models. This paper offers the results of an exploratory mixed methods study that proposes definitions for workarounds and describes the variable relationships with turbulence and patient safety in critical care.

Enhancing Quality and Safety in Critical Care—Challenges and Strategies for Central Venous Catheters

Enhancing Quality and Safety in Critical Care—Challenges and Strategies for Central Venous Catheters

Evaluating the Safety and Efficacy of Naloxegol in Critically Ill Opioid-Induced Constipation Patients.

Background Opioid-induced constipation (OIC) has become more common in the intensive care unit (ICU) due to increased opioid utilization. Traditional laxatives often prove ineffective against OIC, leading to the increased utilization of naloxegol. However, further research is needed to confirm naloxegol's effectiveness and safety in critical care. This study aimed to explore the safety and efficacy of this intervention in critically ill OIC patients. Methods A single-center retrospective study was conducted on 353 patients who received one or more doses of naloxegol from January 1, 2019, to June 30, 2020, for OIC at a tertiary care center. The primary endpoint of this study was to evaluate serious adverse events such as reduced analgesic effect, gastrointestinal perforation, seizure, acute myocardial infarction (AMI), or ventricular arrhythmias using Naranjo Scale in critically ill patients. The secondary goal was to assess the efficacy of naloxegol, measured by the time of the first bowel movement. Results The average duration of naloxegol use was three days, with the first bowel movement occurring at an average of 11.3 hours. Furthermore, 59.8% of individuals had their first bowel movement within 20 hours of receiving naloxegol. There was a low level of causality between naloxegol use and adverse events such as gastrointestinal perforation, seizures, AMI, cardiovascular mortality, stroke, and ventricular arrhythmia. Additionally, reduction in analgesia showed no strong relationship with naloxegol use indicated by the Naranjo Scale assessment. Conclusion Naloxegol showed promising safety and efficacy profiles in treating OIC amongst critically ill patients, though our findings require further validation through prospective studies. This research paves the way for further investigation into naloxegol's role in OIC management, emphasizing the necessity of personalized treatment strategies in critical care settings.

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses

ObjectivesDespite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU)...

Audits in real time for safety in critical care: Definition and pilot study

Adverse events significantly impact upon mortality rates and healthcare costs. PurposeTo design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. MethodsA list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. ResultsThe final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. ConclusionsAudits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

Improving the critical care safety culture

Improving the critical care safety culture

Audits in real time for safety in critical care: Definition and pilot study

Adverse events significantly impact upon mortality rates and healthcare costs. PurposeTo design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. MethodsA list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. ResultsThe final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. ConclusionsAudits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

Board 142 - Program Innovations Abstract 3DiTeams Handover Initiative

Introduction/Background Patient handovers after surgery to intensive care units (ICUs) are replete with communication and technical errors1-3 and studies highlight a relationship between handover quality and patient outcomes.4-6 The Duke Human Simulation and Patient Safety Center received an external educational grant to develop an immersive education environment that aims to improve communication and decrease preventable adverse events in operating room (OR) to neuro ICU handovers. This project used human-centered design (HCD) which incorporates user-centered feedback throughout the development process, thus allowing users to shape the design of the product and enhance its usability to intimately involve users in the refinement of their own handover.7,8 As part of the HCD process, focus groups were conducted with key members in the neuro ICU and OR. Methods Six focus groups were conducted with nurses, residents, fellows, attending physicians and nurse practitioners from the neuro ICU and with anesthesia providers and surgeons from the OR. These guided interviews lasted 30-60 minutes, were separated by role to promote open and honest communicationband utilized a standardized question set that addressed such topics as the responsibility for transmitting and receiving information, information documentation, leadership, problems with the current process and potential solutions. Data analysis was performed using conventional content analysis, a method generally used with a study design whose aim is to describe a phenomenon when existing theory on the topic is limited.to nine Analysis involved the systematic coding of text into categories that characterized and identified key concepts mentioned by the subjects. Focus group participants provided feedback on the current process and discussed the information transfer and available tools to facilitate it, as well as recommendations for improving the physical and information transfers and for developing new handover tools. Most concerning to unit members were missing information (e.g. patient history, patient name and pre-op exam status), multiple conversations, surgeons rushing and not providing enough information and nurses who were unwilling to receive report until the patient was settled in. The analysis revealed that many unit members feel a need for a standardized process, an easy to read, brief, informative summary sheet to be handed over with the patient and a tool to guide the verbal handover. Consistent teams, tasks defined by role and having all members of the team present during the information transfer were also desires expressed by unit members. Results: Conclusion Human-centered design was used to intimately involve educational program participants in designing tools to help improve handovers within their own units. Feedback from participants will be integrated into a multimodal educational program including a virtual environment for learning and practice, on-site clinical observations and technology-mediated coaching. The educational program aims to improve handovers and patient safety in critical care. The final product will be a modular program that can be expanded to address all types of handovers from shift-to-shift to more unit-specific processes.

Building capacity for quality and safety in critical care: A roundtable discussion from the second international patient safety conference in April 9-11, 2013, Riyadh, Saudi Arabia

This paper summarizes the roundtable discussion from the Second International Patient Safety Conference held in April 9-11, 2013, Riyadh, Saudi Arabia. The objectives of the roundtable discussion were to: (1) review the conceptual framework for building capacity in quality and safety in critical care. (2) examine examples of leading international experiences in building capacity. (3) review the experience in Saudi Arabia in this area. (4) discuss the role of building capacity in simulation for patient safety in critical care and (5) review the experience in building capacity in an ongoing improvement project for severe sepsis and septic shock.

Clinical Decision Support Systems for Patient Safety

An ICU is known as a data-rich environment, and information technology can improve the quality of care by utilizing stored clinical data and providing decision support effectively and in a timely manner to clinicians. The necessity of clinical decision support systems is emphasized now more than ever because patient safety and nursing-sensitive outcomes in the clinical setting have become a critical issue. The purpose of this study was to explore nursing-sensitive outcomes issues related to patient safety in critical care and to understand the types and contents of clinical decision support systems that nurses desire in a clinical practice setting. Focus group interviews were conducted with 37 nurses who worked in one university hospital system in Korea. Our findings are summarized into threats to patient safety, nursing-sensitive outcomes, and the types and contents of clinical decision support systems, which are categorized into the following groups: (1) reminders, notification, alert, and warning systems; (2) point-of-care guidelines; and (3) references for information/guidelines. Nurses consistently stated that clinical decision support systems can help improve nursing outcomes by applying standardized nursing care. Our study is expected to provide a practical suggestion for developing and designing a new clinical decision support system or for refining an existing one.

The art of nursing: crossing the quality chasm and promoting patient safety in critical care

Nursing in Critical CareVolume 16, Issue 4 p. 159-160 The art of nursing: crossing the quality chasm and promoting patient safety in critical care Mavilde LG Pedreira, Mavilde LG Pedreira Associate Professor, School of Nursing, Universidade Federal de São Paulo, National Council for Scientific and Technological Development Researcher, São Paulo, BrazilE-mail: mpedreira@unifesp.brSearch for more papers by this author Mavilde LG Pedreira, Mavilde LG Pedreira Associate Professor, School of Nursing, Universidade Federal de São Paulo, National Council for Scientific and Technological Development Researcher, São Paulo, BrazilE-mail: mpedreira@unifesp.brSearch for more papers by this author First published: 09 June 2011 https://doi.org/10.1111/j.1478-5153.2011.00462.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume16, Issue4July/August 2011Pages 159-160 RelatedInformation

Difficult Airway Trolleys for the Critical Care Unit

Airway management is paramount to patient safety in critical care. Intensive Care Society (ICS) standards state that all critical care areas should have a designated difficult airway trolley (DAT) equivalent to that found in operating theatres. We conducted a national survey to determine compliance with this guideline. Adult intensive care units (ICUs) were questioned about the presence of a DAT, its contents and airway training for clinicians. Two hundred and sixty-two ICUs responded to the survey (90%), of which 130 (50%) had a designated DAT. In 38 (29%), a difficult airway management algorithm was available. Capnography was unavailable in 51 (40%) units with a DAT. Compliance with ICS standards and guidelines should be encouraged with respect to DATs. DATs should be available for immediate use within the ICU. Staff should be trained in the use of DAT equipment and be familiar with a difficult airway management algorithm.

Minimising drug errors in critically ill patients

Klopotowska and colleagues underscore the value of the hospital pharmacists’ expertise in reducing medication errors and improving patient safety in critical care [1]. Th e authors emphasise that drug inaccuracies are frequent and that the limited physiological reserve of critically ill individuals increases the potential harm of adverse prescribing. Critically ill patients represent a unique population with altered pharmacokinetics, and it is likely that the rate of suboptimal prescribing may be even greater than suggested by the current study [2,3]. Notably, Klopotowska and colleagues identifi ed that most errors were focused on drug monitoring and suboptimal and incorrect dosing; typically involving antibiotics, drugs used less frequently in critical care and drugs with rapid-change profi les such as anti-thrombotics. It would have been informative to subcategorise errors by clinical grade (intensivist, fellow, resident); however, it is noteworthy that errors increased during the period with new residents. Training is a central issue because there are features unique to prescribing in this population and residents require additional support. Residents are integral to the processes that underpin many risk factors for medication error [4]. From the outset of their critical care experience, residents are required to prescribe drugs not previously encountered and to chart drugs with unfamiliar routes, rates and indications. Th e impact of the limited pharmacy intervention package described in this study [1] could be extended by giving new prescribers an induction focusing on what is unique to critically ill patients. Th is induction might be delivered as an online resource, undertaken prior to starting in critical care and reiterated as help boxes in electronic prescribing.

On the Ball

To explore nursing leadership for patient safety in critical care and identify opportunities to improve leadership that promotes patient safety. There is limited systematic evidence about how nurses lead the microsystem of critical care and to the creation of a culture of patient safety. Focus groups of multidisciplinary frontline providers and managers were used to gain insight into leadership that promotes patient safety and learning. Gains in critical care patient safety require a skilled nursing leader who is mindful of bedside situations and has real-time decision-making authority. Patient safety is seen as management of the moment, rather than a function of organizational systems and processes. Leadership for improved patient safety resides primarily with nurses who provide direct patient care. These nurse leaders play 3 critical roles: they are the "go-to," they are "on the ball," and they "keep the ball rolling."

Safety in Critical Care and Pulmonary Medicine

Safety in Critical Care and Pulmonary Medicine

Tools for ICU patient safety and quality improvement plans. Critical care safety: Essentials for ICU patient care and technology. ECRI Institute Staff. Publisher: ECRI Institute; 146 pages, plus CD

Tools for ICU patient safety and quality improvement plans. Critical care safety: Essentials for ICU patient care and technology. ECRI Institute Staff. Publisher: ECRI Institute; 146 pages, plus CD

The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care

The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care

Orienting frames and private routines: The role of cultural process in critical care safety

Background Being a nurse in the ICU requires extensive clinical knowledge as well as great skill in making stressful decisions and acting decisively while maintaining close working relationships with team members and other hospital staff. Nurses in the ICU draw on social, cognitive, and technological resources to accomplish tasks and achieve goals. Culture is a process that creates and makes available these resources through the situated activities of ICU actors. Aim To understand the means by which cultural process enhances patient safety by establishing and maintaining barriers to adverse events. Methods During the final month of a year-long ethnographic study of patient safety in an ICU, we interviewed nine staff nurses of the unit, and asked them to talk about the details of their work routines. From this talk, and drawing upon our field notes, we identified shared “orienting frames” which are used by nurses to organize, prioritize, conduct, and evaluate their work. Results We report on three orienting frames commonly articulated by interviewees. “Being organized” creates the means for streamlining work in a way that makes it efficient and robust to expected challenges. “Being prepared for emergencies” creates means for effectively coping with the inevitable crises. Finally, “Being responsible and accountable” creates means for nurses to demand resources and to act decisively when they otherwise might not be granted the authority to do so. Conclusions To understand safety in health care, we must go beyond investigating adverse events that arise due to insufficient safety barriers, and study how cultural process creates and maintains these barriers. Understanding cultural process would help improve design and implementation of safety-enhancing interventions and technologies in the ICU.

The Critical Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care

The Critical Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care

The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care*

Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Academic, tertiary-care urban hospital. Medical intensive care unit and coronary care unit patients. None. The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/277), rather than rule-based or knowledge-based mistakes. Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category.