title: Examining the occurrence of adverse events within 72 hours of discharge from the intensive care unit.
abstract: Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for re-admission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a 'do-not-resuscitate' order Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.
authors.affiliation: Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia, Australia.
authors.forename: N
authors.initials: N
authors.lastname: McLaughlin
authors.forename: G D
authors.initials: GD
authors.lastname: Leslie
authors.forename: T A
authors.initials: TA
authors.lastname: Williams
authors.forename: G J
authors.initials: GJ
authors.lastname: Dobb
mesh_terms: D018806:APACHE; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D010343:Patient Admission / Q000706:statistics & numerical data*; D010351:Patient Discharge; D011446:Prospective Studies; D013997:Time Factors