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Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system
1Intensive Care Unit, Ostschweizer Kinderspital, Claudiusstrasse 6, CH-9006 St.Gallen, Switzerland. bernhard.frey@bluewin.ch
Insights
Critical incidents (CIs) are frequent in pediatric intensive care, with management, drugs, and procedures being common categories. Analyzing these CIs is crucial for improving patient safety and quality of care.
Area of Science:
- Pediatric Intensive Care Medicine
- Patient Safety Research
- Healthcare Quality Improvement
Background:
- Critical incidents (CIs) are events that could compromise patient safety.
- Understanding CI occurrence is vital for enhancing care quality in pediatric intensive care units (ICUs).
Purpose of the Study:
- To investigate the frequency and nature of critical incidents (CIs) in a neonatal-pediatric intensive care unit (ICU).
- To identify contributing factors and categories of CIs to inform quality improvement strategies.
Main Methods:
- A prospective survey was conducted over one year in a multidisciplinary pediatric ICU.
- Anonymous, non-punitive monitoring of CIs was performed, with severity graded based on patient harm.
- Data from 467 admissions were analyzed, focusing on CI categories, severity, and contributing factors.
Main Results:
- 211 CIs were reported, with 30% major, 25% moderate, and 45% minor.
- Common CI categories included management/environment (29%), drugs (29%), and procedures (18%).
- Respiratory CIs were most severe, while drug-related CIs, including decimal point errors, were frequent. Human error was the primary contributing factor (63%).
Conclusions:
- Critical incidents are highly prevalent in pediatric intensive care settings.
- System-based analysis of CIs provides valuable insights for targeted quality improvement initiatives.
- Addressing human errors and system deficiencies is key to reducing CI occurrence and enhancing patient safety.
Objective:
To examine the occurrence of critical incidents (CIs) in order to improve quality of care.
Design:
Prospective survey.
Setting:
Multidisciplinary, neonatal-pediatric intensive care unit (ICU) of a non-university, teaching children's hospital.
Patients:
Four hundred and sixty-seven admissions over a 1-year period.
Methods:
A CI is any event which could have reduced, or did reduce, the safety margin for the patient. Comprehensive, anonymous, non-punitive CI monitoring was undertaken. CI severity with respect to actual patient harm was graded: major (score 3), moderate (2) or minor (1). The system approach incorporates the philosophy that errors are evidence of deficiencies in systems, not in people. We undertook 2-monthly analyses of CIs.
Results:
There were 211 CI reports: 30 % major, 25 % moderate, 45 % minor. The CI categories were management/environment 29 %, drugs 29 %, procedures 18 %, respiration 14 %, equipment dysfunction 7 %, nosocomial infections 3 %. The respiratory CIs were the most severe, the drug-related CIs the least severe (score mean, SD: 2.9, 0.26 vs 1.4, 0.76; p < 0.001). However, 20 out of 62 drug-related CIs were potentially life-threatening. Thirteen percent of drug CIs were decimal point errors. Eleven of the 29 respiratory CIs were accidental extubations (2.6/100 ventilator days). CIs were most often precipitated by consultants (32 %), followed by residents (23 %, over-represented in drug CIs, 22/62) and specialized nurses (21 %). Doctors had a greater proportion of major CIs than nurses (p < 0.01). Fifty percent of the CIs were detected by routine checks. The most important method of detection was patient inspection (44 %), alarms accounted for only 10 %. Contributing factors were human errors (63 %), communication failure (14 %), organizational problems (10 %), equipment dysfunction (7 %) and milieu (3 %).
Conclusions:
CIs are very common in pediatric intensive care. Knowledge of them is a precious source for quality improvement through changes in the system.