title: A review of patient safety incidents reported as 'severe' or 'death' from critical care units in England and Wales between 2004 and 2014.
abstract: We analysed 1743 patient safety incidents reported between 2004 and 2014 from critical care units in England and Wales where the harm had been classified as 'severe' (1346, 77%) or 'death' (397, 23%). We classified 593 (34%) of these incidents as resulting in temporary harm, and 782 (45%) as more than temporary harm, of which 389 (22%) may have contributed to the patient's death. We found no described harm in 368 (21%) incidents. We classified 1555 (89%) of the incidents as being avoidable or potentially avoidable. There were changes over time for some incident types (pressure sores: 10 incidents in 2007, 64 in 2012; infections: 60 incidents in 2007, 10 in 2012) and some changes in response to national guidance. We made a comparison with a dataset of all incidents reported from units in North-West England, and this confirmed that the search strategy identified more severe incidents, but did not identify all incidents that contributed to mortality.
authors.affiliation: Salford Royal NHS Foundation Trust, Salford, UK.
authors.forename: A N
authors.initials: AN
authors.lastname: Thomas
authors.affiliation: Health Education North West Training Scheme, Manchester, UK.
authors.forename: J J
authors.initials: JJ
authors.lastname: MacDonald
mesh_terms: D003422:Critical Care; D004739:England; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008485:Medical Audit; D019300:Medical Errors / Q000401:mortality* / Q000706:statistics & numerical data*; D008875:Middle Aged; D061214:Patient Safety / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D014852:Wales
keywords: complications; critical care; critical incidents; patient safety