title: A multifaceted program for improving quality of care in intensive care units: IATROREF study.
abstract: OBJECTIVE
  To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs.
  
  
  METHODS
  Multicenter cluster-randomized study.
  
  
  METHODS
  One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group.
  
  
  METHODS
  Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units.
  
  
  METHODS
  We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period.
  
  
  RESULTS
  Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect.
  
  
  CONCLUSIONS
  A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00461461.
authors.affiliation: Medical-Surgical Intensive Care Unit, Saint Joseph Hospital Network, Paris, France. mgarrouste@hpsj.fr
authors.forename: Maite
authors.initials: M
authors.lastname: Garrouste-Orgeas
authors.forename: Lilia
authors.initials: L
authors.lastname: Soufir
authors.forename: Alexis
authors.initials: A
authors.lastname: Tabah
authors.forename: Carole
authors.initials: C
authors.lastname: Schwebel
authors.forename: Aurelien
authors.initials: A
authors.lastname: Vesin
authors.forename: Christophe
authors.initials: C
authors.lastname: Adrie
authors.forename: Marie
authors.initials: M
authors.lastname: Thuong
authors.forename: Jean Francois
authors.initials: JF
authors.lastname: Timsit
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods; D016000:Cluster Analysis; D016001:Confidence Intervals; D003422:Critical Care / Q000458:organization & administration; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D017052:Hospital Mortality; D006764:Hospitals, Community; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods; D007902:Length of Stay; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D061214:Patient Safety; D015397:Program Evaluation; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D018570:Risk Assessment; D017751:Safety Management / Q000458:organization & administration*
chemical_list: D000925:Anticoagulants