title: A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS).
abstract: OBJECTIVE
  To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine.
  
  
  METHODS
  Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS).
  
  
  METHODS
  Sixteen adult and two pediatric intensive care units (ICU) across the United States.
  
  
  METHODS
  Incidents reported during the 12-month period ending June 30, 2003.
  
  
  METHODS
  None
  
  
  METHODS
  Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events.
  
  
  RESULTS
  There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32).
  
  
  CONCLUSIONS
  Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.
authors.affiliation: Pulmonary & Critical Care Medicine, and Dana Center for Preventive Ophthalmology Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Dale M
authors.initials: DM
authors.lastname: Needham
authors.forename: David A
authors.initials: DA
authors.lastname: Thompson
authors.forename: Christine G
authors.initials: CG
authors.lastname: Holzmueller
authors.forename: Todd
authors.initials: T
authors.lastname: Dorman
authors.forename: Lisa H
authors.initials: LH
authors.lastname: Lubomski
authors.forename: Albert W
authors.initials: AW
authors.lastname: Wu
authors.forename: Laura L
authors.initials: LL
authors.lastname: Morlock
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence / Q000592:standards; D015897:Comorbidity; D016208:Databases, Factual; D004868:Equipment Failure / Q000706:statistics & numerical data; D005190:Family / Q000523:psychology; D006302:Health Services Research; D006801:Humans; D007223:Infant; D007362:Intensive Care Units / Q000458:organization & administration*; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D019300:Medical Errors / Q000009:adverse effects / Q000379:methods / Q000517:prevention & control / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D020380:Needs Assessment / Q000458:organization & administration; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration; D012307:Risk Factors; D012308:Risk Management / Q000458:organization & administration*; D013597:Systems Analysis; D014139:Tracheostomy / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology