Research
Major sources of critical incidents in intensive care
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* Corresponding author: Richard Wenstone Richard.Wenstone@rlbuht.nhs.uk
1 Intensive Care Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
2 Institute of Ageing and Chronic Disease, University of Liverpool, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK
3 Moredata GmbH, Kerkrader Str. 11, D-35394 Giessen, Germany
Critical Care 2011, 15:R232 doi:10.1186/cc10474
See related commentary by Kiekkas et al., http://ccforum.com/content/16/1/102
Published: 29 September 2011Abstract
Introduction
In recent years, critical incident (CI) reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.
Methods
The study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit (ICU). Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health & safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.
Results
A total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 (30%), clinical practice 257 (22.8%), pharmaceuticals 238 (21.1%), administration 213 (18.9%), health and safety hazards 81 (7.2%). The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.
Conclusions
Critical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.