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

• Published in: Intensive care medicine Vol. 27; no. 1; pp. 137 - 145
• Main Authors: BRACCO, David, FAVRE, Jean-Baptiste, BISSONNETTE, Bruno, WASSERFALLEN, Jean-Blaise, REVELLY, Jean-Pierre, RAVUSSIN, Patrick, CHIOLERO, René
• Format: Journal Article
• Language: English
• Published: Heidelberg Springer 2001; Berlin Springer Nature B.V
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Analysis of Variance; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Aviation; Biological and medical sciences; Cardiology; Catheters; Child; Child, Preschool; Female; Health care; Hospital Costs; Hospital Mortality; Hospitals; Human error; Humans; Intensive care; Intensive care medicine; Intensive Care Units - standards; Internal medicine; Length of Stay; Male; Medical Errors - economics; Medical Errors - statistics & numerical data; Medical sciences; Medicine; Middle Aged; Miscellaneous; Multivariate Analysis; Nurses; Patients; Prospective Studies; Pulmonary arteries; Risk; Surveillance; Switzerland - epidemiology; Task Performance and Analysis; Switzerland; Human; Mishap; Intensive care; Prognosis; Disease; Epidemiology; Human factor; Morbidity; Intensive care unit; Incidence; Human error; Quality assurance; Quality; Risk factor
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s001340000751

To determine the incidence and identify risk factors of critical incidents in an ICU. Prospective observational study of consecutive patients admitted over 1 year to an ICU. Critical incidents were recorded using predefined criteria. Their causes and consequences were analysed. The causes were classified as technical failure, patient's underlying disease, or human errors (subclassified as planning, execution, or surveillance). The consequences were classified as lethal, leading to sequelae, prolonging the ICU stay, minor, or without consequences. The correlation between critical incidents and specific factors including patient's diagnosis and severity score, use of monitoring and therapeutic modalities was analysed by uni- and multivariate analysis. An 11-bed multidisciplinary ICU in a non-university teaching hospital. 1,024 consecutive patients admitted to the ICU. None. The median length of ICU stay by the 1,024 patients was 1.9 days. Of the 777 critical incidents reported 2% were due to technical failure and 67 % to secondary to underlying disease. There were 241 human errors (31%) in 161 patients, evenly distributed among planning (n = 75), execution (n = 88), and surveillance (n = 78). One error was lethal, two led to sequelae, 26 % prolonged ICU stay, and 57 % were minor and 16 % without consequence. Errors with significant consequences were related mainly to planning. Human errors prolonged ICU stay by 425 patient-days, amounting to 15 % of ICU time. Readmitted patients had more frequent and more severe critical incidents than primarily admitted patients. Critical incidents add morbidity, workload, and financial burden. A substantial proportion of them are related to human factors with dire consequences. Efforts must focus on timely, appropriate care to avoid planning and execution mishaps at the beginning of the ICU stay; surveillance intensity must be maintained, specially after the fourth day.