Disclosing errors and adverse events in the intensive care unit*

"Mind the Gap"-Differences between Documentation and Reality on Intensive Care Units: A Quantitative Observational Study

INTRODUCTION

Digitalization in medicine is steadily increasing. Complex treatments, scarce personnel resources and a high level of documentation are a constant burden on healthcare systems. The balancing between correct manual documentation in the digital records and limited staff resources is rarely successful. The aim of this study is to evaluate the adherence between documentation and lack of documentation in the treatment of critical care patients.

MATERIAL AND METHODS

For the evaluation, data from the hospital information system (HIS) of several intensive care units (ICU) were examined in conjunction with data collected from a checklist. All boluses of sedatives, analgesics and catecholamines were documented paper based across all shifts and all weekdays and compared with corresponding digital data from the HIS (2019-2022) of previous years.

RESULTS

939 complete digital patient records revealed a massive under-documentation of the medication administration compared to that applied according to the checklist. Only 12% of all administered catecholamines, 11% of α2-agonists, 33% of propofol, 92% of midazolam and 46% of opioids were found in the digital recordings. In comparison, the effect was more pronounced on weekdays compared to weekends. In addition, the highest documentation gap was found in the comparison of early shifts. Comparing neurosurgical vs. internal vs. anesthesiologic ICUs there was a highly significant difference between anesthesiologic ICUs compared with other disciplines (p < 0.0001).

DISCUSSION

Our data shows that there is a remarkable documentation gap and incongruence in the area of applied boli. Automated documentation by connecting syringe pumps that enter data directly into the HIS can not only reduce the workload, but also lead to comprehensive and legally required documentation of all administered medication.

State-of-the art training in neonatal resuscitation

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors

BACKGROUND

Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors.

OBJECTIVE

To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors.

METHODS

This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors.

RESULTS

A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%).

CONCLUSION

Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

The association between self-reported workload and perceptions of patient safety culture: A study of intensive care unit nurses

AIM AND OBJECTIVE

This study aimed to examine the association between workload and patient safety culture (PSC) among intensive care unit (ICU) nurses.

BACKGROUND

ICU nurses play a vital role in promoting patient safety and are essential indicators in any healthcare system including ICUs. Research studies focusing on the relationship between nursing workload and PSC among ICU nurses are limited.

DESIGN

Descriptive correlational design.

METHODS

The study participants involved 380 ICU nurses at two hospitals in Riyadh, Saudi Arabia. Data were collected between February 2019-April 2019 and were analysed using SPSS v.22 statistical software. This study was guided by the STROBE checklist.

RESULTS

The results showed that ICU nurses have high positive perceptions in the following PSC subscales: teamwork within units, organisational learning-continuous improvement, frequency of events reported, feedback and communication about error, management support for patient safety, teamwork across units, supervisor/manager expectations and actions promoting patient safety, handoffs and transitions, nonpunitive response to errors, staffing and overall perceptions of patient safety. However, the participants collectively considered the overall grade on patient safety as poor. The participants had high mean scores in physical demand, effort, mental demand and overall workload. A statistically significant variability existed in the mean scores of the PSC subscales and workload of ICU nurses. The overall workload was significantly and negatively associated with the PSC perceptions of ICU nurses.

CONCLUSION

The ICU nurses experienced high overall workload, physical demand, effort and mental demand which influenced the poor grade of their overall perceived PSC.

RELEVANCE TO CLINICAL PRACTICE

Identifying differences and associations with the perceptions of ICU nurses regarding workload and PSC is important because such perceptions may affect their delivery of nursing care. Hospital and nursing administrators must use the study results to find strategies that address workload issues and enhance patient safety.

Hospital Image Repair Strategies, Organizational Apology, and Medical Errors: An Analysis of the CoxHealth Brain Over-Radiation Case

Medical errors are currently ranked the third leading cause of death in United States; however, hospital responses when one occurs have been left out of organizational crisis and image repair literature. This article reports an image repair analysis of the 2010 CoxHealth radiation medical error case, when 76 patients accidentally received fatally high doses of radiation for the treatment of brain cancer. CoxHealth used a variety of image repair strategies including shifting the blame, minimization, bolstering, and corrective action. Moreover, CoxHealth heavily used transcendence to transform the conversation from the error to activism to frame themselves as change agents championing for patient safety.

Identification of adverse events in pediatric severe traumatic brain injury patients to target evidence-based prevention for increased performance improvement and patient safety

INTRODUCTION

Trauma centres are required to continuously measure, evaluate and improve care. Severe traumatic brain injury (sTBI) patients are highly susceptible to adverse events (AE; unintended, potentially harmful events resulting from health care) due to their unstable condition requiring high risk interventions, multiple medications and invasive monitoring. Objectives were to describe: (1) a process for identifying AE in pediatric sTBI patients to identify safety risks, target and implement evidence-based prevention strategies; and (2) a tertiary care PICU's sTBI AE experience.

METHODS

Merging databases, Trauma Registry with Adverse Events Management System, identified AE in patients. Details on the event location, type and severity of harm were combined with patient demographics, injury data, costs and outcomes in a cohort of 193 PICU sTBI patients (2000-15). Descriptive statistics and multivariate logistic regression were undertaken to describe AE, and their association with risk factors and outcomes.

RESULTS

103/193 sTBI patients (53%) suffered at least one AE. 238 AE occurred (1.23 AE/patient), with 30% of patients having 2+ AE. Most resulted in no harm (54%) with decubitus ulcers (15%) the most common AE. AE patients were more likely to be monitored for elevated ICP (p<0.001), with fewer ventilator-free days (p=0.015), longer LOS for PICU (11 vs. 3.5 days; p<0.001) and in-hospital (31 vs. 11 days; p<0.001) with higher median costs ($121,234 vs. $53,341; p=0.031). AE patients required a higher level of care on discharge (p=0.035).

CONCLUSIONS

Merging databases is an effective practice to identify AE and safety risks in trauma populations. Utilizing this method, a PICU AE rate of 1.23 events per patient was found with TBI severity the most important factor to increase the odds of AE. AE represent performance improvement events, opportunities to optimize care, decrease costs, as well as improve outcomes, to ultimately improve patient safety in this vulnerable population.

Recommendations to prevent nursing errors: Content analysis of semi-structured interviews with intensive care unit nurses in a developing country

AIM

To elicit intensive care unit (ICU) nurses' recommendations to prevent nursing errors.

BACKGROUND

Errors are usually induced by faulty systems, and managers play a key role in building a safe health care system.

METHOD

A qualitative research design was used. Semi-structured interviews with 112 Egyptian ICU nurses were conducted, and responses were analysed using qualitative content analysis.

RESULTS

Responses from 108 nurses were analysed. Six themes of recommendations were identified: improvement and better organisation of resources, policy modification, education and training, likeness minimization, use of technology and work environment changes.

CONCLUSION

Nurses' recommendations reflect the poor-resource context in developing countries. Several recommendations, however, are relatively cheap to implement strategies.

IMPLICATIONS FOR NURSING MANAGEMENT

All reported recommendations are organisational issues. Improvement and better organisation of human and non-human resources is a priority issue to prevent or minimize nursing errors. Policy modification, education and training, and likeness minimization are relatively cheap, easy-to-implement strategies to tackle the occurrence of nursing errors in developing countries. Staff nurses should be actively involved in policy reform. Patient safety education should be supported by adopting modern technology and work environment reform.

Disclosing adverse events and near misses to parents of neonates

Critically ill newborns receiving intensive and complex care may be subject to medical errors and adverse events. Like most physicians, neonatologists do not feel comfortable disclosing their errors and may need assistance in learning how to do so. Understanding useful models of error disclosure, and communication training, will likely be beneficial.

Nature of nursing errors and their contributing factors in intensive care units

BACKGROUND

Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety.

AIM

To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs).

METHODS

A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis.

RESULTS

A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient.

CONCLUSIONS

Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness.

RELEVANCE TO CLINICAL PRACTICE

Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety.

Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists

BACKGROUND

Health care professionals who are frequently coping with traumatic events have an increased risk of developing a posttraumatic stress disorder. Research among physicians is scarce, and obstetrician-gynecologists may have a higher risk. Work-related traumatic events and posttraumatic stress disorder among obstetricians-gynecologists and the (desired) type of support were studied.

METHODS

A questionnaire was emailed to all members of the Dutch Society of Obstetrics and Gynaecology, which included residents, attending, retired and non-practicing obstetricians-gynecologists. The questionnaire included questions about personal experiences and opinions concerning support after work-related events, and a validated questionnaire for posttraumatic stress disorder.

RESULTS

The response rate was 42.8% with 683 questionnaires eligible for analysis. 12.6% of the respondents have experienced a work-related traumatic event, of which 11.8% met the criteria for current posttraumatic stress disorder. This revealed an estimated prevalence of 1.5% obstetricians-gynecologists with current posttraumatic stress disorder. 12% reported to have a support protocol or strategy in their hospital after adverse events. The most common strategies to cope with emotional events were: to seek support from colleagues, to seek support from family or friends, to discuss the case in a complication meeting or audit and to find distraction. 82% would prefer peer-support with direct colleagues after an adverse event.

CONCLUSIONS

This survey implies that work-related events can be traumatic and subsequently can lead to posttraumatic stress disorder. There is a high prevalence rate of current posttraumatic stress disorder among obstetricians-gynecologists. Often there is no standardized support after adverse events. Most obstetrician-gynecologists prefer peer-support with direct colleagues after an adverse event. More awareness must be created during medical training and organized support must be implemented.

Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families

OBJECTIVE

Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts.

DATA SOURCES

Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched.

STUDY SELECTION

Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations.

DATA EXTRACTION

Our group determined by consensus which resources would best inform this review.

DATA SYNTHESIS

A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded.

CONCLUSIONS

Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Application of Bow-tie methodology to improve patient safety

Purpose - The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach - Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings - In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value - The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

Nursing workload and occurrence of adverse events in intensive care: a systematic review

OBJECTIVE

To identifyevidences of the influence of nursing workload on the occurrence of adverse events (AE) in adult patients admitted to the intensive care unit (ICU).

METHOD

A systematic literature review was conducted in the databases MEDLINE, CINAHL, LILACS, SciELO, BDENF, and Cochrane from studies in English, Portuguese, or Spanish, published by 2015. The analyzed AE were infection, pressure ulcer (PU), patient falls, and medication errors.

RESULTS

Of 594 potential studies, eight comprised the final sample of the review. TheNursing Activities Score (NAS; 37.5%) and the Therapeutic Intervention Scoring System(TISS; 37.5%) were the instruments most frequently used for assessing nursing workload. Six studies (75.0%) identified the influence of work overload in events of infection, PU, and medicationerrors. An investigation found that the NAS was a protective factor for PU.

CONCLUSION

The nursing workload required by patients in the ICU influenced the occurrence of AE, and nurses must monitor this variable daily to ensure proper sizing of staff and safety of care.

OBJETIVO

Identificar evidências sobre a influência da carga de trabalho de enfermagem na ocorrência de eventos adversos (EA) em pacientes adultos internados em Unidade de Terapia Intensiva (UTI).

MÉTODO

Revisão sistemática da literatura realizada nas bases de dados MEDLINE, CINAHL, LILACS, SciELO, BDENF e Cochrane deestudosem inglês, português ou espanhol, publicados até 2015. Os EA analisados foram infecção, úlcera por pressão (UPP), quedas e erros associados a medicamentos.

RESULTADOS

Das 594 pesquisas potenciais identificadas, oito compuseram a amostra final da revisão. O NursingActivities Score -NAS (37,5%) e o TherapeuticInterventionScoring System -TISS (37,5%) foram os instrumentos mais utilizados para avaliação da carga de trabalho de enfermagem. Seis pesquisas (75,0%) identificaram influência da sobrecarga de trabalho na ocorrência de infecção, UPP e uso de medicamentos. Uma investigação identificou que o NAS foi fator de proteção para UPP.

CONCLUSÃO

A carga de trabalho de enfermagem requerida por pacientes na UTI influenciou a ocorrência de EA, e os enfermeiros devem monitorar diariamente esta variável para garantir o correto dimensionamento da equipe e a segurança da assistência prestada.

Standardized patient simulation versus didactic teaching alone for improving residents' communication skills when discussing goals of care and resuscitation: A randomized controlled trial

BACKGROUND

Communication skills are important when discussing goals of care and resuscitation. Few studies have evaluated the effectiveness of standardized patients for teaching medical trainees to communicate about goals of care.

OBJECTIVE

To determine whether standardized patient simulation offers benefit over didactic sessions alone for improving skill and comfort discussing goals of care.

DESIGN AND INTERVENTION

Single-blind, randomized, controlled trial of didactic teaching plus standardized patient simulation versus didactic teaching alone.

PARTICIPANTS

First-year internal medicine residents.

MAIN MEASURES

Changes in communication comfort and skill between baseline and 2 months post-training assessed using the Consultation and Relational Empathy measure.

KEY RESULTS

We enrolled 94 residents over a 2-year period. Both groups reported a significant improvement in comfort when discussing goals of care with patients. There was no difference in Consultation and Relational Empathy scores following the workshop ( p = 0.79). The intervention group showed a significant increase in Consultation and Relational Empathy scores post-workshop compared with pre-workshop (35.0 vs 31.7, respectively; p = 0.048), whereas there was no improvement in Consultation and Relational Empathy scores in the control group (35.6 vs 36.0; p = 0.4). However, when the results were adjusted for baseline differences in Consultation and Relational Empathy scores in a multivariable regression analysis, group assignment was not associated with an improvement in Consultation and Relational Empathy score. Improvement in comfort scores and perception of benefit were not associated with improvements in Consultation and Relational Empathy scores.

CONCLUSION

Simulation training may improve communication skill and comfort more than didactic training alone, but there were important confounders in this study and further studies are needed to determine whether simulation is better than didactic training for this purpose.

The development of a congenital heart programme quality dashboard to promote transparent reporting of outcomes

In 2001, the Institute of Medicine identified healthcare transparency as a necessity for re-designing a quality healthcare system; however, despite widespread calls for publicly available transparent data, the goal remains elusive. The transparent reporting of outcome data and the results of congenital heart surgery is critical to inform patients and families who have both the wish and the ability to choose where care is provided. Indeed, in an era where data and means of communication of data have never been easier, the paucity of transparent data reporting is paradoxical. We describe the development of a quality dashboard used to inform staff, patients, and families about the outcomes of congenital heart surgery at the Stollery Children's Hospital.

An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes?

Medical malpractice lawsuits are a growing problem in the United States, and there is much controversy regarding how to best address this problem. The medical error disclosure framework suggests that apologizing, expressing empathy, engaging in corrective action, and offering compensation after a medical error may improve the provider-patient relationship and ultimately help reduce the number of medical malpractice lawsuits patients bring to medical providers. This study provides an experimental examination of the medical error disclosure framework and its effect on amount of money requested in a lawsuit, negative intentions, attitudes, and anger toward the provider after a medical error. Results suggest empathy may play a large role in providing positive outcomes after a medical error.

MERIS (Medical Error Reporting Information System) as an innovative patient safety intervention: a health policy perspective

The economic crisis in Greece poses the necessity to resolve problems concerning both the spiralling cost and the quality assurance in the health system. The detection and the analysis of patient adverse events and medical errors are considered crucial elements of this course. The implementation of MERIS embodies a mandatory module, which adopts the trigger tool methodology for measuring adverse events and medical errors an intensive care unit [ICU] environment, and a voluntary one with web-based public reporting methodology. A pilot implementation of MERIS running in a public hospital identified 35 adverse events, with approx. 12 additional hospital days and an extra healthcare cost of €12,000 per adverse event or of about €312,000 per annum for ICU costs only. At the same time, the voluntary module unveiled 510 reports on adverse events submitted by citizens or patients. MERIS has been evaluated as a comprehensive and effective system; it succeeded in detecting the main factors that cause adverse events and discloses severe omissions of the Greek health system. MERIS may be incorporated and run efficiently nationally, adapted to the needs and peculiarities of each hospital or clinic.

Error in intensive care: psychological repercussions and defense mechanisms among health professionals

OBJECTIVE

To identify the psychological repercussions of an error on professionals in intensive care and to understand their evolution. To identify the psychological defense mechanisms used by professionals to cope with error.

DESIGN

Qualitative study with clinical interviews. We transcribed recordings and analysed the data using an interpretative phenomenological analysis.

SETTING

Two ICUs in the teaching hospitals of Besançon and Dijon (France).

SUBJECTS

Fourteen professionals in intensive care (20 physicians and 20 nurses).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted 40 individual semistructured interviews. The participants were invited to speak about the experience of error in ICU. The interviews were transcribed and analyzed thematically by three experts. In the month following the error, the professionals described feelings of guilt (53.8%) and shame (42.5%). These feelings were associated with anxiety states with rumination (37.5%) and fear for the patient (23%); a loss of confidence (32.5%); an inability to verbalize one's error (22.5%); questioning oneself at a professional level (20%); and anger toward the team (15%). In the long term, the error remains fixed in memory for many of the subjects (80%); on one hand, for 72.5%, it was associated with an increase in vigilance and verifications in their professional practice, and on the other hand, for three professionals, it was associated with a loss of confidence. Finally, three professionals felt guilt which still persisted at the time of the interview. We also observed different defense mechanisms implemented by the professional to fight against the emotional load inherent in the error: verbalization (70%), developing skills and knowledge (43%), rejecting responsibility (32.5%), and avoidance (23%). We also observed a minimization (60%) of the error during the interviews.

CONCLUSIONS

It is important to take into account the psychological experience of error and the defense mechanisms developed following an error because they appear to determine the professional's capacity to acknowledge and disclose his/her error and to learn from it.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

Background

Practicing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.

Methods

We carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.

Results

We identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.

Conclusion

In complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Institutional disclosure: promise and problems

This study explores rationale for and barriers to the prompt and honest disclosure by healthcare organizations of care-related un-intended harm to patients. Although fear of legal action is frequently put forward as the reason that disclosure programs have been slow to be adopted by the medical community, social and nonjurisprudential explanations also pose challenges. This study identifies multiple facilitators and obstacles that transcend concerns about litigation and limit disclosure of adverse events that result in serious injury or death.

Crew resource management in the ICU: the need for culture change

Intensive care frequently results in unintentional harm to patients and statistics don't seem to improve. The ICU environment is especially unforgiving for mistakes due to the multidisciplinary, time-critical nature of care and vulnerability of the patients. Human factors account for the majority of adverse events and a sound safety climate is therefore essential. This article reviews the existing literature on aviation-derived training called Crew Resource Management (CRM) and discusses its application in critical care medicine. CRM focuses on teamwork, threat and error management and blame free discussion of human mistakes. Though evidence is still scarce, the authors consider CRM to be a promising tool for culture change in the ICU setting, if supported by leadership and well-designed follow-up.

Inappropriate trust in technology: implications for critical care nurses

AIMS AND OBJECTIVES

To explore evidence from the literature that critical care nurses may have inappropriate levels of trust in the technological equipment they use and the implications of this for patient safety.

BACKGROUND

Nurses in intensive care units are required to observe the operation of an array of complex equipment. Failure of this equipment can have potentially fatal consequences for the patient. Research from other settings, such as the work of airline pilots, suggests that experienced operators of highly reliable automation may display inappropriately high levels of trust in the automation and this can lead to inadequate monitoring of the equipment by the operator. Inadequate monitoring means that the operator may fail to notice that the equipment is not functioning correctly which may have serious consequences.

SEARCH METHODS

An initial search was made of a number of databases including Academic Search Premier, CINAHL, Pubmed and ScienceDirect. Extensive use was also made of citations found in articles uncovered by this initial search.

CONCLUSIONS

Evidence suggests that there is potential for critical care nurses to display complacent attitudes. In addition, there are a number of reasons why the consequences of this complacency are not as visible as in other settings.

IMPLICATIONS FOR PRACTICE

If nurses are not aware of the potential and consequences of inappropriate trust, there is a real possibility that patients may suffer harm because of it. There is an urgent need for more research to identify direct evidence of complacency and its consequences. There is also a need for these issues to be highlighted in the training of intensive care nurses and there are implications for intensive care unit practice protocols and equipment manufacturers.

Medical error and decision making: Learning from the past and present in intensive care

BACKGROUND

Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

PURPOSE

The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

DATA SOURCE

Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

FINDINGS

Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

CONCLUSION

It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II

RATIONALE

Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention.

OBJECTIVES

We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality.

METHODS

We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales.

MEASUREMENTS AND MAIN RESULTS

Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039).

CONCLUSIONS

The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.

[Safety and quality in intensive care medicine]

The safety and quality care are two attributes of the health care that are closely intertwined. Quality is a feature of the system that delivers health care, thereby improving it, we need a proper reorganization teamwork. Measurements of quality are intended to assess whether the process of health care reaches the desired objectives, while avoiding the processes that predispose to harm the patient. The critically ill patients are vulnerable to medical errors, and may experience side effects preventable, often associated with: medications, mechanical ventilation, and intravascular devices. The evidence currently available suggest that the safety and quality of care can be improved. In this article presents some of the strategies and interventions developed to optimize the processes of care in critically ill patients, and improve the safety culture in the ICU.

Teaching error disclosure to residents: a curricular innovation and pilot study

OBJECTIVE

To compare change in obstetrics and gynecology residents' self-efficacy in disclosing medical errors after a formal educational session.

METHODS

This was a retrospective postintervention survey to assess change in perceived preparedness to disclose medical errors. We used a 4-hour educational seminar that included a didactic component (30 minutes) and experiential learning with a trained facilitator (3 hours). Change in self-efficacy was measured using a 5-point Likert-type scale (1 is lowest, and 5 is highest) and was compared using sign test (α  =  .05).

RESULTS

In our pilot study, 13 of 15 residents reported having previously participated in error disclosure. After the session, residents considered themselves more prepared for the following: to know what to include in and how to introduce error discussions, to deal with a patient's emotional reaction, to respond to a patient's questions regarding how an error occurred, and to recognize one's own emotions when discussing medical errors. Residents believed that they would be likely to use the skills learned in the remainder of residency and in their future career.

CONCLUSIONS

This curriculum was associated with improvement in self-efficacy regarding error disclosure. Given the unique malpractice issues that obstetricians/gynecologists face, it seems particularly useful for residents to learn these skills early in their career. In addition, this topic represents an ideal educational opportunity for residencies to improve patient care and to address other core competencies in resident education such as communication skills and professionalism.

Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare)

New modes of mechanical ventilation with advanced closed loops are now available, and in the future these could assume a greater role in supporting critically ill patients in intensive care units (ICUs) for several reasons. Two modes of ventilation--proportional assist ventilation and neurally adjusted ventilatory assist--deliver assisted ventilation proportional to the patient's effort, improving patient-ventilator synchrony. Also, a few systems that automate the medical reasoning with advanced closed-loops, such as SmartCare and adaptive support ventilation, have the potential to improve knowledge transfer by continuously implementing automated protocols. Moreover, they may improve patient-ventilator interactions and outcomes, and provide a partial solution to the forecast clinician shortages by reducing ICU-related costs, time spent on mechanical ventilation, and staff workload. Preliminary studies are promising, and initial systems are currently being refined with increasing clinical experience. A new era of mechanical ventilation should emerge with these systems.

Medical malpractice and the chest physician

The US malpractice system is based on tort law, which holds physicians responsible for not harming patients intentionally or through negligence. Malpractice claims are brought against physicians from most medical disciplines in proportion to their numbers in practice and to the frequency with which they perform procedures. Claims against chest physicians most commonly allege injuries caused by the following: (1) errors in diagnosis, (2) improper performance of procedures, (3) failure to supervise or monitor care, (4) medication errors, and (5) failure to recognize the complications of treatment. Most of these injuries occur in hospitals, and many of the injured patients die. The social goals of the medical malpractice system include the following: (1) compensating patients injured through negligence, (2) exacting corrective justice, and (3) deterring unsafe practices by creating an economic incentive to take greater precautions. Some patients injured through negligence are compensated, but most are not. Claims are brought against some negligent physicians but also some who are not negligent, and being negligent does not guarantee that a claim will be brought. The deterrent effect of medical malpractice is unproven, and the malpractice system may prompt defensive medicine and increase health-care costs. And by stressing individual accountability, it conflicts with a systems-oriented approach to reducing medical errors.

Safety in obstetric critical care

High-profile inquiries in several countries have helped to raise public awareness of safety issues and driven policy change. In obstetric critical care, various publications have highlighted organizational factors, communication, absence of guidelines, failure to follow local protocols, poor documentation and delay in identifying the deteriorating woman as issues. Patient safety in obstetric critical care is paramount because of its complexity and the vulnerability of the critically ill patient to error. The principles of risk management and its various components can be used to make improvements. A framework to achieve this is as follows: building a safety culture; leading and supporting staff; integrating risk management activity; promoting reporting; involving and communicating with patients and the public; learning and sharing safety lessons; and implementing solutions to prevent harm.

Impact of adverse events on outcomes in intensive care unit patients

OBJECTIVE

To examine the association between predefined adverse events (AE) (including nosocomial infections) and intensive care unit (ICU) mortality, controlling for multiple adverse events in the same patient and confounding variables.

DESIGN

Prospective observational cohort study of the French OUTCOMEREA multicenter database.

SETTING

Twelve medical or surgical ICUs.

PATIENTS

Unselected patients hospitalized for > or = 48 hrs enrolled between 1997 and 2003.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 3,611 patients included, 1415 (39.2%) experienced one or more AEs and 821 (22.7%) had two or more AEs. Mean number of AEs per patient was 2.8 (range, 1-26). Six AEs were associated with death: primary or catheter-related bloodstream infection (BSI) (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.6-5.32), BSI from other sources (OR, 5.7; 95% CI, 2.66-12.05), nonbacteremic pneumonia (OR, 1.69; 95% CI, 1.17-2.44), deep and organ/space surgical site infection without BSI (OR, 3; 95% CI, 1.3-6.8), pneumothorax (OR, 3.1; 95% CI, 1.5-6.3), and gastrointestinal bleeding (OR, 2.6; 95% CI, 1.4-4.9). The results were not changed when the analysis was confined to patients with mechanical ventilation on day 1, intermediate severity of illness (Simplified Acute Physiology Score II between 35 and 55), no treatment-limitation decisions, or no cardiac arrest in the ICU.

CONCLUSIONS

AEs were common and often occurred in combination in individual patients. Several AEs independently contributed to death. Creating a safe ICU environment is a challenging task that deserves careful attention from ICU physicians.

Closed-loop ventilation: an emerging standard of care?

The rational for using closed loop ventilation is becoming strong and stronger. Studies are now available supporting the hypothesis that patient outcome is improved by using closed loop ventilation. In the highly sophisticated ICU world driven by the triumvirate of cost-efficiency, quality, and safety, closed loop ventilation will become definitely unavoidable. The challenge is how to make that change effortless, "friendly" and as fast as possible. Introducing novel graphical user interfaces and providing data displays that are pertinent, integrative and dynamic will reduce cognitive resources of the clinician and have the potential to make ventilation safer. They may be the key to adopt closed loop ventilation in everyday practice.

The Five A's: what do patients want after an adverse event?

After an adverse event, Five A's: Acknowledgment, Apology, All the Facts, Assurance and Appropriate Compensation, serve to meet the essential needs of patients and their families. This simple mnemonic creates a clear framework of understanding for the actions health professionals need to take to manage errors and adverse events in an empathic and patient-oriented fashion. While not all patients demand or need compensation, most need at least the first four A's. Patient-centered communication using this simple framework following an adverse event will foster a climate of understanding and frank discussion, addressing the emotional and physical needs of the whole patient and family.