Reporting of medical errors: an intensive care unit experience.
OBJECTIVE
To determine the occurrence and type of medical errors in an intensive care setting using a voluntary reporting method.


METHODS
Prospective, single-center, observational study.


METHODS
The medical intensive care unit (19 beds) at an urban teaching hospital.


METHODS
Adult patients requiring at least 48 hrs of intensive care.


METHODS
Prospective reporting of medical errors.


RESULTS
During a 6-month period, 232 medical events were reported involving 147 patients. A total of 2598 patient days were surveyed yielding 89.3 medical events reported per 1000 intensive care unit days. The source of the reports included nurses, who reported most of the medical events (59.1%), followed by physicians-in-training (27.2%) and intensive care unit attending physicians (2.6%). One hundred thirty (56.2%) medical events occurred within the intensive care unit and were judged to involve patient careproviders who were working directly in the intensive care unit area. One hundred and two (43.8%) medical events were commissions or omissions that occurred outside of the intensive care unit during patient transports or in the emergency department and hospital floors. Twenty-three (9.9%) medical events leading to a medical error resulted in the need for additional life-sustaining treatment, and seven (3.0%) medical errors may have contributed to patient deaths.


CONCLUSIONS
Medical errors appear to be common among patients requiring intensive care. Medical events resulting in an error can result in the need for additional life-sustaining treatments and, in some circumstances, can contribute to patient death. Patient healthcare providers appear to be in a unique position to identify medical errors. Institutions should develop formalized methods for the reporting and analysis of medical errors to improve patient care.
Osmon
Stephen
S
Pulmonary and Critical Care Division, Washington University School of Medicine, St. Louis, MO, USA.
Harris
Carolyn B
CB
Dunagan
W Claiborne
WC
Prentice
Donna
D
Fraser
Victoria J
VJ
Kollef
Marin H
MH
D005568:Forms and Records Control; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data; D008923:Missouri; D009741:Nursing Staff, Hospital / Q000706:statistics & numerical data; D019370:Observation; D011446:Prospective Studies; D012308:Risk Management / Q000379:methods / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014342:Truth Disclosure