, Volume 32, Issue 10, pp 1591-1598
Date: 28 Jul 2006

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study

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Abstract

Objective

To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs).

Design

An observational, 24-h cross-sectional study of incidents in five representative categories.

Setting

205 ICUs worldwide

Measurements

Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.

Results

In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7–42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00–1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18–2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04–1.08).

Conclusions

Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.

On behalf of the Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM) and the SEE study investigators
This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-006-0291-6