Errors in the intensive care unit (ICU). Experiences with an anonymous registration

Area of Science:

• Medical Safety
• Intensive Care Medicine
• Healthcare Quality Improvement

Background:

• Investigated the occurrence and severity of errors within a combined ICU and postoperative ward at a Norwegian University Hospital.
• Aims to provide insights into patient safety in critical care settings.

Purpose of the Study:

• To quantify the frequency and assess the severity of errors in an intensive care unit (ICU).
• To understand the types of errors and their consequences on patient outcomes.

Main Methods:

• Anonymous registration of errors over 13 months (October 1995 - November 1996).
• Data collected included error type, patient demographics, condition, location, and consequences graded on a 6-point scale.
• Errors were independently evaluated by intensivists and nurses using a Visual Analogue Scale (VAS).

Main Results:

• A total of 87 errors were reported, with medication errors (41.3%) being the most frequent.
• Intravenous infusion issues (19.5%) and technical equipment failure (17.2%) were also significant.
• Most errors (63%) had no detectable consequences; however, five errors had serious consequences, including one fatality.

Conclusions:

• Errors are a common occurrence in the ICU setting.
• The reported incidence likely underestimates the true frequency of errors.
• Despite frequent errors, many have limited patient impact, though serious events do occur.