Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.
OBJECTIVE
To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs).


METHODS
An observational, 24-h cross-sectional study of incidents in five representative categories.


METHODS
205 ICUs worldwide


METHODS
Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.


RESULTS
In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7-42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00-1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18-2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04-1.08).


CONCLUSIONS
Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.
Valentin
Andreas
A
KA Rudolfstiftung, II. Medical Department, Juchgasse 25, 1030 Vienna, Austria. andreas.valentin@meduniwien.ac.at
Capuzzo
Maurizia
M
Guidet
Bertrand
B
Moreno
Rui P
RP
Dolanski
Lorenz
L
Bauer
Peter
P
Metnitz
Philipp G H
PG
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D004868:Equipment Failure; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008875:Middle Aged; D011159:Population Surveillance; D017751:Safety Management