title: Critical incident reporting in the intensive care unit.
abstract: Critical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our "system' and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.
authors.affiliation: Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong.
authors.forename: T A
authors.initials: TA
authors.lastname: Buckley
authors.forename: T G
authors.initials: TG
authors.lastname: Short
authors.forename: Y M
authors.initials: YM
authors.lastname: Rowbottom
authors.forename: T E
authors.initials: TE
authors.lastname: Oh
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D004868:Equipment Failure; D006723:Hong Kong; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D019300:Medical Errors; D008991:Monitoring, Physiologic; D015397:Program Evaluation; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012308:Risk Management / Q000379:methods*