SICU Critical Care Safety Study

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SICU Critical Care Safety Study

  1. 1. SICU Journal Club: The Critical Care Safety Study July 25, 2007 Christopher J. Utz, MD
  2. 2. <ul><li>Institute of Medicine report estimated medical errors cause 44,000-98,000 deaths each year </li></ul><ul><li>Critical care may incur higher rates of medical error </li></ul><ul><li>Critically ill patients may be more vulnerable to iatrogenic injury </li></ul>Background:
  3. 3. Study Objectives <ul><li>Primary: Determine the incidence and rates of adverse events and serious errors per 1000 patient-days </li></ul><ul><li>Secondary: </li></ul><ul><ul><li>Categorize types of errors </li></ul></ul><ul><ul><li>Identify Human factors and system factors associated with errors </li></ul></ul>
  4. 4. Methods <ul><li>Definitions </li></ul><ul><ul><li>Adverse Event – any injury due to medical management, rather than the underlying disease </li></ul></ul><ul><ul><ul><li>Nonpreventable adverse event – unavoidable injury due to appropriate medical care </li></ul></ul></ul><ul><ul><ul><li>Preventable adverse event – injury due to a nonintercepted serious error in medical care </li></ul></ul></ul><ul><ul><li>Medical Error – failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim </li></ul></ul><ul><ul><ul><li>Serious medical error – a medical error that causes harm (or injury) or has the potential to cause harm. </li></ul></ul></ul>
  5. 5. Methods <ul><li>Definitions </li></ul><ul><ul><li>Adverse Event – any injury due to medical management, rather than the underlying disease </li></ul></ul><ul><ul><ul><li>Nonpreventable adverse event – unavoidable injury due to appropriate medical care </li></ul></ul></ul><ul><ul><ul><li>Preventable adverse event – injury due to a nonintercepted serious error in medical care </li></ul></ul></ul><ul><ul><li>Medical Error – failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim </li></ul></ul><ul><ul><ul><li>Serious medical error – a medical error that causes harm (or injury) or has the potential to cause harm. </li></ul></ul></ul><ul><ul><ul><ul><li>Intercepted serious error – serious medical error that is caught before reaching the patient </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nonintercepted serious error – serious medical error that reaches the patient but because of good fortune or because the patient had sufficient reserves to buffer the error, it did not cause clinically detectable harm. </li></ul></ul></ul></ul>
  6. 6. Methods <ul><ul><li>10 beds each w/ closed attending model </li></ul></ul><ul><ul><li>Adult patients – boarders & patients with < 4 hour stay excluded </li></ul></ul><ul><ul><li>Patients followed until transfer, unit discharge, or death </li></ul></ul>Patient population: MICU & CCU of 720 bed tertiary care hospital
  7. 7. Methods <ul><li>4 pronged data collection: </li></ul><ul><ul><li>Direct continuous observation of on-call interns both day and night by research physicians </li></ul></ul><ul><ul><ul><li>Interns responsible for new admissions and entire unit overnight (on call Q 3 days) </li></ul></ul></ul><ul><ul><ul><li>Activities of interest – PE, order entry, teaching & work rounds, medical procedures, & interpretation of test results </li></ul></ul></ul><ul><ul><li>Anonymous & formal incident reports </li></ul></ul><ul><ul><li>Computerized adverse drug event detection monitor </li></ul></ul><ul><ul><li>Chart review and abstraction by trained research nurses </li></ul></ul>
  8. 8. <ul><li>Data Classification </li></ul><ul><ul><li>2 physician investigators independently classified each incident </li></ul></ul><ul><ul><li>Judged severity on 4-point scale (significant, severe, life-threatening, fatal) </li></ul></ul><ul><ul><li>Classified events as preventable or not preventable </li></ul></ul><ul><ul><li>Errors classified according to clinical activity (prevention, diagnosis, treatment, procedures, monitoring, & communicating clinical information) </li></ul></ul><ul><ul><li>Further classified by individual and system based factors </li></ul></ul><ul><ul><li>Rater disagreements resolved by discussion </li></ul></ul>Methods
  9. 9. Results Data collected during nine 3-wk periods (5 in MICU, 4 in CCU) Observed 391 patients 420 admissions 1490 patient-days Patient demographics are different between MICU and CCU
  10. 10. Results <ul><li>120 Adverse events in 79 patients (20.2%) – rate of 81 adverse events/1000 pt-days </li></ul><ul><ul><li>6.4% of patients had multiple events </li></ul></ul><ul><ul><li>45% of adverse events were judged to be preventable </li></ul></ul>223 Serious errors – rate of 150 serious errors/1000 pt-days
  11. 11. Results <ul><li>16 life-threatening and 2 fatal adverse events </li></ul><ul><ul><li>Fatal events due to catheter-related bloodstream infections </li></ul></ul>24 serious errors judged to be potentially life-threatening
  12. 12. Results Incident Stats: Discovery of Adverse events & nonintercepted serious errors Patient’s nurse (36%) Another physician (27%) Clinical pharmacist (12%) Responsible physician (9%) Chart review (11%) Intercepted serious errors Patient’s nurse (42%) Another physician (23%) Clinical pharmacist (17%) <ul><li>Majority of incidents occurred during routine care (91%) w/ far fewer </li></ul><ul><ul><li>w/in 30 min of admission to the unit (4%) or </li></ul></ul><ul><ul><li>during an emergency intervention (2%) </li></ul></ul>
  13. 13. Results 56 (47%) of adverse events due to ADE including 19 preventable ADE’s Medications contributed to 78% of serious errors Medication errors most commonly associated w/ treatment (87%) Also associated w/ prevention, diagnosis, & monitoring
  14. 14. Results Human & System Factors <ul><li>Incidents due to errors most common during </li></ul><ul><ul><li>treatments & procedures (75%) – particularly the ordering or execution of medications (61%) </li></ul></ul><ul><ul><li>reporting or communicating clinical info (14%) </li></ul></ul><ul><ul><li>failure to take precautions or follow protocol during preventive or diagnostic activities (11%) </li></ul></ul><ul><ul><li>failure to take precautions or follow protocol during treatment or procedure activities (8%) </li></ul></ul><ul><li>Performance level failures judged as </li></ul><ul><ul><li>Skill-based slips & lapses (53%) </li></ul></ul><ul><ul><li>knowledge-based mistakes (26%) </li></ul></ul><ul><ul><li>rule-based mistakes (5%) </li></ul></ul><ul><li>Sterility hazards </li></ul><ul><ul><li>failure to wash hands (51%) </li></ul></ul><ul><ul><li>failure to use complete cap, gown, & gloves (16%) </li></ul></ul><ul><ul><li>failure to properly use sterile drapes (6%) </li></ul></ul><ul><ul><li>sterile field violations (17%) </li></ul></ul>
  15. 15. Discussion Results comparable to prior MICU studies w/ similar definitions Error rates similar in MICU and CCU Most of the errors categorized as slips & lapses – failure to carry out intended plans of action Based on this study, the authors estimate that 148,000 life-threatening intercepted & nonintercepted serious errors occur annually in teaching hospitals <ul><li>Authors focus on system-based changes as a means for error prevention </li></ul><ul><ul><li>Computerized physician order entry </li></ul></ul><ul><ul><li>Bar-coded medication administration </li></ul></ul>
  16. 16. Discussion Study limitations Primarily studied interns May not be generalizable to ICU’s w/ markedly different patient populations May not be generalizable to non-teaching ICU’s
  17. 17. Questions?
  18. 18. Additional Info

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