Critical Path Network: ICU patients at risk for preventable errors
Critical Path Network
ICU patients at risk for preventable errors
AHRQ study puts spotlight on adverse events
Patients face a significant risk for preventable adverse events and serious medical errors in hospital critical care units, according to a study sponsored by the Agency for Healthcare Research and Quality (AHRQ). The study, "The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care," was published in the August issue of Critical Care Medicine.
The researchers found that more than 20% of the patients admitted to two intensive care units at an academic hospital, a medical intensive care unit (MICU), and a coronary critical care unit (CCU) experienced an adverse event. Of the adverse events in the sample, almost half (45%) were preventable. A significant number of the adverse events involved medications — most commonly, giving patients the wrong dose. More than 90% of all incidents occurred during routine care, not on admission or during an emergency intervention.
The researchers conducted direct continuous observations in the MICU and CCU during nine three-week periods, distributed throughout 12 months from July 2002 through June 2003. This was supplemented by confidential incident reporting, a computerized adverse drug event detection monitor, and chart reviews.
This study was part of a larger research effort examining the effect of eliminating extended work shifts and work hours on serious medical errors by interns, explains lead author Jeffrey M. Rothschild, MD, MPH, assistant professor of medicine at Harvard Medical School, and a member of the division of general medicine at Brigham & Women’s Hospital in Boston. "This was a secondary analysis," he explains. "The method was we followed the interns but reported any errors we found."
While noting that the findings may not be generalizable because Brigham & Women’s is a teaching hospital, Rothschild adds that "we have certain built-in elements that reduce errors, like computerized physician order entry [CPOE], pharmacists participating on rounds, and full-time attendings in the unit. But to counterbalance that, [patients in the ICU] unit may be sicker than in other places, so the number of events may not be generalizable."
The findings are nevertheless important, he continues, because critical care units provide an increasingly greater proportion of care. "During our lifetimes, we can expect to be admitted to an ICU at least once. We hope these findings will stimulate the adoption of known interventions, like ensuring hand washing, better physician/nurse communications, and greater use of health IT [information technology]," he says.
Rothschild asserts that the results (i.e., 45% of the adverse events being preventable) are "quite consistent with the research we’ve seen elsewhere."
What did surprise him slightly, he says, was that most of the errors were the kinds that could easily be fixed. "They involved lapses in care — forgetting to do the right thing, forgetting to start certain meds, or slips in which [the provider] incorrectly ordered something because they entered the wrong amount or ordered it for the wrong patient," he notes. These types of errors, he points out, can be more easily corrected than things such as making the wrong diagnosis, or problems associated with procedures.
Perhaps equally surprising is the fact that a little more than 60% of the adverse events involved medications — most commonly, giving patients the wrong dose. With all the national attention being given to medication safety, is Rothschild concerned we are we still not making progress?
"There isn’t really hard data to prove it, but we do have a general sense that patient safety is more on the minds of clinicians, and the hospitals are taking a closer look at what kinds of interventions have worked," he asserts. "In general, most hospitals are making a better effort to identify opportunities for improvement; I have a sense we are going in the right direction, but we have a real long way to go."
It is Rothschild’s hope that these findings "will stimulate the adoption of known interventions" to reduce errors in the future.
Improving communications among clinicians and between disciplines is a clear opportunity, he continues. "Everyone who’s caring for the patient should share the same mental model and view of what’s going on with that patient and should develop more teamwork in the units," he advises. "Another element is really pushing protocols and compliance with protocols."
One surprising finding, for example, was how often sterile procedures were done without complete sterile techniques. "Hand washing is still a tremendous problem," Rothschild observes. "But there are ways to improve; we now have waterless systems at every bedside, which makes it so much easier than going to the sink. That kind of innovative approach works."
He also sees technological opportunities. "We already have CPOE," he notes. "More [computerized] decision support would protect slips in dosing errors. And there are certainly opportunities in medication administration, with smart pumps and bar coding, though the data on those are still not strong yet."
Earlier studies also have shown that that extended work hours and fatigue present real problems, he adds, noting that his final take-home message is that the number of critical care patients is expanding. "In many hospitals, a quarter of the beds are in an ICU — and that is certainly where the sickest patients go — so it is an important area to concentrate our efforts on improving safety," says Rothschild.
Patients face a significant risk for preventable adverse events and serious medical errors in hospital critical care units, according to a study sponsored by the Agency for Healthcare Research and Quality (AHRQ).Subscribe Now for Access
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