title: An analysis of near misses identified by anesthesia providers in the intensive care unit.
abstract: BACKGROUND
  Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations.
  
  
  METHODS
  We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations.
  
  
  RESULTS
  A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02).
  
  
  CONCLUSIONS
  A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA. lipshutza@anesthesia.ucsf.edu.
authors.forename: Angela K M
authors.initials: AK
authors.lastname: Lipshutz
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA. caldwell@anesthesia.ucsf.edu.
authors.forename: James E
authors.initials: JE
authors.lastname: Caldwell
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA. robinowitzd@anesthesia.ucsf.edu.
authors.forename: David L
authors.initials: DL
authors.lastname: Robinowitz
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA. gropperm@anesthesia.ucsf.edu.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gropper
mesh_terms: D058109:Airway Management / Q000592:standards; D000758:Anesthesia / Q000592:standards / Q000706:statistics & numerical data*; D000776:Anesthesiology / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000706:statistics & numerical data*; D019300:Medical Errors / Q000517:prevention & control; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D012189:Retrospective Studies