Human errors in a multidisciplinary intensive care unit: a 1-year prospective study

Bracco, David; Favre, Jean-Baptiste; Bissonnette, Bruno; Wasserfallen, Jean‐Blaise; Revelly, Jean-Pierre; Ravussin, P.; Chioléro, René

doi:10.1007/s001340000751

Cited by 154 publications

(99 citation statements)

References 14 publications

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“…14,[16][17][18][19] We found that 36% of adverse events and 6.1% of in-ICU deaths were certainly or probably preventable, in agreement with previously published data. Our analysis also showed that the impact of disease severity at ICU admission on the preventability of events diverged between deaths and adverse events.…”

Section: Timing Of Adverse Eventssupporting

confidence: 92%

“…[14][15][16][17][18][19] Nevertheless, data on the rates of adverse events and medical errors in ICUs are contradictory because nosocomial infections and iatrogenic complications due to invasive procedures or medications are not always preventable. 14,17,18 In addition, adverse events are often responsible for patients' being transferred to the ICU, further complicating the analysis of preventability of accidental injuries in ICUs. 19 Therefore, the rates of preventable adverse events per 1000 ICU patient-days are estimated to be between 13 and 40, and in-ICU medical errors could prolong the ICU stay by 15% and increase hospital costs by 10%.…”

Section: Literature Reviewmentioning

confidence: 99%

“…19 Therefore, the rates of preventable adverse events per 1000 ICU patient-days are estimated to be between 13 and 40, and in-ICU medical errors could prolong the ICU stay by 15% and increase hospital costs by 10%. 14,17,19 To confront this important health care problem, high-risk specialties, like surgery or anesthesiology, have successfully improved the quality of care they provide and the safety of their patients by systematizing morbidity and mortality conferences (MMCs). 4,20 Indeed, MMCs for care providers are a traditional means of improving local care management through the discussion of adverse events, complications, or medical errors and the conception of alternative approaches to medical decision making.…”

Section: Literature Reviewmentioning

confidence: 99%

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Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

Ksouri

Balanant

Tadié

et al. 2010

American Journal of Critical Care

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Background Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units. Objectives To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety. Methods For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24–48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability. Results During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred. Conclusion In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.

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Section: Timing Of Adverse Eventssupporting

confidence: 92%

Section: Literature Reviewmentioning

confidence: 99%

Section: Literature Reviewmentioning

confidence: 99%

See 1 more Smart Citation

Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

Ksouri

Balanant

Tadié

et al. 2010

American Journal of Critical Care

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“…These human errors are frequent and may be associated with high morbidity and mortality. 2,3 An optimal device for emergency care should provide adequate technical performance, combined with optimal ergonomics (ie, an easy-to-use and user-friendly human/machine interface). 4,5 Significant improvement in the technical performance of emergency and transport ventilators has been observed during the last decade, 6 and more recent devices have demonstrated technical performance similar to that of ICU ventilators.…”

Section: Introductionmentioning

confidence: 99%

A Comprehensive Approach for the Ergonomic Evaluation of 13 Emergency and Transport Ventilators

Marjanovic

L’Her

2016

Respir Care

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BACKGROUND: Mechanical ventilation is an important part of emergency medicine and is frequently used for transportation. Human errors during ventilator settings are frequent and may be associated with high morbidity/mortality. The aim of the study was to provide a complete ergonomic evaluation of emergency and transport ventilators, taking into account objective and subjective human-machine interface assessments and individual mental work load. METHODS: We performed a prospective bench ergonomic evaluation of 13 emergency and transport ventilators, using standardized conditions and a global methodological approach. The study was performed in an evaluation laboratory dedicated to respiratory care, and 12 emergency physicians unfamiliar with the tested devices were included in the evaluation. The ventilators were classified into 3 categories (simple, sophisticated, and ICU-like). Objective chronometric evaluations were conducted considering 9 tasks, and subjective evaluations were performed (ease of use, willingness to use, and user-friendliness of monitoring) using Likert scales. Mental work load evaluation was performed using the NASA Task Load Index scale. RESULTS: Overall task failure rate represented 4% of all attempts. Setting modifications, ventilation mode changes, and powering down durations were different between simple and other emergency and transport ventilator categories (P < .005). There was no difference between ventilator categories for the ease of use and userfriendliness of the monitoring. In contrast, the willingness to use was lower for simple devices, compared with sophisticated and ICU-like emergency and transport ventilators (2.9 ؎ 1.4 vs 3.9 ؎ 1.2, P ‫؍‬ .002 and 4.3 ؎ 1, P < .001). No differences were observed between devices regarding the mental work load, except for several specific devices in the sophisticated category. CONCLUSIONS: A comprehensive ergonomic evaluation provides valuable information while investigating operational friendliness in emergency and transport ventilators. The choice of a device not only depends on its technical characteristics but should take into account its clinical operational setting and ergonomics in order to decrease mental work load. Sophisticated emergency and transport ventilators should only be used by clinicians who demonstrate expertise in mechanical ventilation.

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“…As a consequence, decision making and safety may be a challenge in routine practice. It has been emphasized that human error is responsible of the majority of medical accidents [6] and that most of these accidents are considered avoidable [7]. In this context, the development of user-machine interfaces specifically designed to facilitate cognitive processes may increase the ease of care giver interactions and reduce the number of accidents.…”

mentioning

confidence: 99%

ICU mechanical ventilators, technological advances vs. user friendliness: the right picture is worth a thousand numbers

Richard

Kacmarek

2009

Intensive Care Med

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Human errors in a multidisciplinary intensive care unit: a 1-year prospective study

Cited by 154 publications

References 14 publications

Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

A Comprehensive Approach for the Ergonomic Evaluation of 13 Emergency and Transport Ventilators

ICU mechanical ventilators, technological advances vs. user friendliness: the right picture is worth a thousand numbers

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