2016
DOI: 10.1111/anae.13547
|View full text |Cite
|
Sign up to set email alerts
|

A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Abstract: SummaryWe analysed 1743 patient safety incidents reported between 2004 and 2014 from critical care units in England and Wales where the harm had been classified as 'severe' (1346, 77%) or 'death' (397, 23%). We classified 593 (34%) of these incidents as resulting in temporary harm, and 782 (45%) as more than temporary harm, of which 389 (22%) may have contributed to the patient's death. We found no described harm in 368 (21%) incidents. We classified 1555 (89%) of the incidents as being avoidable or potentiall… Show more

Help me understand this report

Search citation statements

Order By: Relevance

Paper Sections

Select...
1
1

Citation Types

1
20
0

Year Published

2016
2016
2021
2021

Publication Types

Select...
9

Relationship

0
9

Authors

Journals

citations
Cited by 17 publications
(21 citation statements)
references
References 17 publications
1
20
0
Order By: Relevance
“…Using this model, a substantial amount of effort has been devoted to examining the sequence of events leading up to accidents to try to understand how the accident came about and thus help to prevent recurrence. This approach was adopted in aviation and subsequently in healthcare, in the NHS and especially in anaesthesia . A typical approach is depicted in Fig.…”
Section: The Three ‘Ages’ Of Safetymentioning
confidence: 99%
“…Using this model, a substantial amount of effort has been devoted to examining the sequence of events leading up to accidents to try to understand how the accident came about and thus help to prevent recurrence. This approach was adopted in aviation and subsequently in healthcare, in the NHS and especially in anaesthesia . A typical approach is depicted in Fig.…”
Section: The Three ‘Ages’ Of Safetymentioning
confidence: 99%
“…One reason is that some research questions simply cannot be tackled using the randomised controlled format . There is also much to gain from analyses, for instance of routinely‐collected data, as these can make initial sense of what is held, help establish trends and formulate hypotheses for further testing . We should also remember that the systematic review, much vaunted as the highest level of clinical research evidence, has a retrospective character too.…”
Section: Retrospective Studiesmentioning
confidence: 99%
“…Nasogastric tube (NGT) insertion is common in the intensive care unit for enteral feeding. However, it is not without procedural complications, including epistaxis and even oesophageal perforation , and severe patient safety incidents have been reported . We recently experienced a case of polyurethane NGT rupture using the new Enfit™ (CORPAK MedSystems, Inc., USA) safety system .…”
mentioning
confidence: 99%