Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study
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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).
An observational, 24-h cross-sectional study of incidents in five representative categories.
205 ICUs worldwide
Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.
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).
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.
KeywordsCritical care Patient safety Incident reporting
The SEE study was supported by the Austrian Center for Documentation and Quality Assurance in Intensive Care Medicine (ASDI) and endorsed by the European Critical Care Research Network (ECCRN) of the European Society of Intensive Care Medicine (ESICM). We are indebted to Mary McKenney for editorial advice and to Gerhard Krenn for programming the study website. We are most grateful to the staff of all the ICUs that contributed to the SEE study. A list of persons in charge of the study at the ICU level and their corresponding country is provided in the electronic supplementary material.
- 1.Kohn LT, Corrigan KM, Donaldson MS, (eds) (1999) To err is human: building a safer health system. Washington DC, National Academy PressGoogle Scholar
- 14.Vincent JL, Moreno R, Takala J, Willats S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710PubMedGoogle Scholar
- 29.Beydon L, Conreux F, Le Gall R, Safran D, Cazalaa JB (2001) Sous-commission de Materiovigilance for Anaesthesia and Intensive Care. Analysis of the French health ministry's national register of incidents involving medical devices in anaesthesia and intensive care. Br J Anaesth 86:382–387PubMedCrossRefGoogle Scholar