Intensive Care Medicine

, Volume 32, Issue 10, pp 1591–1598 | Cite as

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

  • Andreas Valentin
  • Maurizia Capuzzo
  • Bertrand Guidet
  • Rui P. Moreno
  • Lorenz Dolanski
  • Peter Bauer
  • Philipp G. H. Metnitz
Original

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.

Keywords

Critical care Patient safety Incident reporting 

Supplementary material

134_2006_290_MOESM1_ESM.doc (398 kb)
Electronic Supplementary Material (DOC 398K)

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Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Andreas Valentin
    • 1
  • Maurizia Capuzzo
    • 2
  • Bertrand Guidet
    • 3
  • Rui P. Moreno
    • 4
  • Lorenz Dolanski
    • 5
  • Peter Bauer
    • 5
  • Philipp G. H. Metnitz
    • 6
  1. 1.II. Medical DepartmentKA RudolfstiftungViennaAustria
  2. 2.Department of Anesthesia & Intensive CareUniversity Hospital of FerraraFerraraItaly
  3. 3.Departement Réanimation MédicaleHôpital Saint AntoineParisFrance
  4. 4.Unidade de Cuidados Intensivos PolivalenteHospital de St. António dos Capuchos, Centro Hospitalar de Lisboa (Zona Central)LisboaPortugal
  5. 5.Department of Medical StatisticsMedical University of ViennaViennaAustria
  6. 6.Department of Anesthesiology and General Intensive CareMedical University of ViennaViennaAustria

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