Critical incidents in a multidisciplinary intensive care unit.
We aimed to determine the type and frequency of critical incidents in a multidisciplinary intensive care unit, to determine outcomes consequent to these incidents and to devise corrective strategies. Prospectively collected data on critical incidents during a 33-month period were analysed. In all, 1918 patients were admitted to the unit during the study period. Each incident was analysed in detail. A system-based corrective strategy was sought for and implemented as appropriate. In these patients, 280 critical incidents were reported during the study period, resulting in 3.4 incidents per 100 patient days. Airway-related incidents were the most frequent (32.8%) followed by line-related (21.8%) and drug-related (15%) incidents. Thirty-two incidents (11.4%) led to adverse outcomes. There were four deaths that occurred as a direct consequence of or contributed to by the incident, all due to airway-related incidents. A major physiological change occurred in 3.6% of incidents, while 6.4% of incidents resulted in a minor physiological change. Critical incidents were common in our multidisciplinary ICU, although adverse outcomes were rare.
Chacko
J
J
Multidisciplinary Intensive Care Unit, Manipal Hospital, Bangalore, India.
Raju
H R
HR
Singh
M K
MK
Mishra
R C
RC
D003625:Data Collection / Q000379:methods; D004868:Equipment Failure; D006470:Hemorrhage / Q000188:drug therapy*; D006801:Humans; D007194:India; D007362:Intensive Care Units / Q000592:standards*; D019300:Medical Errors / Q000145:classification / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000145:classification / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012308:Risk Management; D013597:Systems Analysis