title: Delayed Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures: A Root Cause Analysis of Unplanned ICU Admissions.
abstract: BACKGROUND
  An unplanned ICU admission of an inpatient is a serious adverse event (SAE). So far, no in depth-study has been performed to systematically analyse the root causes of unplanned ICU-admissions. The primary aim of this study was to identify the healthcare worker-, organisational-, technical,- disease- and patient- related causes that contribute to acute unplanned ICU admissions from general wards using a Root-Cause Analysis Tool called PRISMA-medical. Although a Track and Trigger System (MEWS) was introduced in our hospital a few years ago, it was implemented without a clear protocol. Therefore, the secondary aim was to assess the adherence to a Track and Trigger system to identify deterioration on general hospital wards in patients eventually transferred to the ICU.
  
  
  METHODS
  Retrospective observational study in 49 consecutive adult patients acutely admitted to the Intensive Care Unit from a general nursing ward. 1. PRISMA-analysis on root causes of unplanned ICU admissions 2. Assessment of protocol adherence to the early warning score system.
  
  
  RESULTS
  Out of 49 cases, 156 root causes were identified. The most frequent root causes were healthcare worker related (46%), which were mainly failures in monitoring the patient. They were followed by disease-related (45%), patient-related causes (7, 5%), and organisational root causes (3%). In only 40% of the patients vital parameters were monitored as was instructed by the doctor. 477 vital parameter sets were found in the 48 hours before ICU admission, in only 1% a correct MEWS was explicitly documented in the record.
  
  
  CONCLUSIONS
  This in-depth analysis demonstrates that almost half of the unplanned ICU admissions from the general ward had healthcare worker related root causes, mostly due to monitoring failures in clinically deteriorating patients. In order to reduce unplanned ICU admissions, improving the monitoring of patients is therefore warranted.
authors.affiliation: Department of Internal Medicine, Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Louise S
authors.initials: LS
authors.lastname: van Galen
authors.affiliation: Department of Internal Medicine, Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Patricia W
authors.initials: PW
authors.lastname: Struik
authors.affiliation: Department of Internal Medicine, Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Babiche E J M
authors.initials: BE
authors.lastname: Driesen
authors.affiliation: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: Hanneke
authors.initials: H
authors.lastname: Merten
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Ludikhuize
authors.affiliation: Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Johannes I
authors.initials: JI
authors.lastname: van der Spoel
authors.affiliation: Department of Internal Medicine, Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Mark H H
authors.initials: MH
authors.lastname: Kramer
authors.affiliation: Department of Internal Medicine, Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Prabath W B
authors.initials: PW
authors.lastname: Nanayakkara
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D057210:Delayed Diagnosis / Q000523:psychology / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D019300:Medical Errors / Q000523:psychology / Q000706:statistics & numerical data; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000523:psychology / Q000706:statistics & numerical data; D012189:Retrospective Studies; D060891:Root Cause Analysis