Intensive Care Medicine

, Volume 39, Issue 3, pp 391–398 | Cite as

Safety climate reduces medication and dislodgement errors in routine intensive care practice

  • Andreas Valentin
  • Michael Schiffinger
  • Johannes Steyrer
  • Clemens Huber
  • Guido Strunk



To assess the frequency and contributing factors of medication and dislodgement errors attributable to common routine processes in a cohort of intensive care units, with a special focus on the potential impact of safety climate.


A prospective, observational, 48 h cross sectional study in 57 intensive care units (ICUs) in Austria, Germany, and Switzerland, with self-reporting of medical errors by ICU staff and concurrent assessment of safety climate, workload and level of care.


For 795 observed patients, a total of 641 errors affecting 269 patients were reported. This corresponds to a rate of 49.8 errors per 100 patient days related to the administration of medication, loss of artificial airways, and unplanned dislodgement of lines, catheters and drains. In a multilevel model predicting error occurrence at the patient level, odds ratios (OR) per unit increase for the occurrence of at least one medical error were raised for a higher Nine Equivalents of Nursing Manpower Use Score (NEMS) (OR 1.04, 95 % CI 1.02–1.05, p < 0.01) and a higher number of tubes/lines/catheters/drains (OR 1.02, 95 % CI 1.01–1.03, p < 0.01) at the patient level and lowered by a better safety climate at the ICU level (OR per standard deviation 0.67, 95 % CI 0.51–0.89, p < 0.01).


Safety climate apparently contributes to a reduction of medical errors that represent a particularly error-prone aspect of frontline staff performance during typical routine processes in intensive care.


Patient safety Medical error Safety climate Intensive care unit Quality of health care 



We thank the ICU teams and ICU study coordinators (see supplemental digital content) who participated in this study and contributed in an open-minded and dedicated fashion. This study was conducted as a joint research project and financed by the Vienna Mayor’s Medical-Scientific Fund and the Austrian Center for Documentation and Quality Assurance in Intensive Care (ASDI). The study was supported by the German Interdisciplinary Federation of Intensive Care Medicine and Emergency Medicine (DIVI) and the Suisse Society of Intensive Care Medicine (SGI). Last but not least, our thanks go to the editor and reviewers for their critical yet constructive remarks on previous versions of this manuscript.

Supplementary material

134_2012_2764_MOESM1_ESM.doc (48 kb)
Supplementary material 1. Safety climate reduces medication and dislodgement errors in routine intensive care practice (DOC 47 kb)


  1. 1.
    Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D (2010) Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 340:c309PubMedCrossRefGoogle Scholar
  2. 2.
    Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, Metnitz P (2009) Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 338:b814PubMedCrossRefGoogle Scholar
  3. 3.
    Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med 32:1591–1598PubMedCrossRefGoogle Scholar
  4. 4.
    Garrouste-Orgeas M, Timsit JF, Vesin A, Schwebel C, Arnodo P, Lefrant JY, Souweine B, Tabah A, Charpentier J, Gontier O, Fieux F, Mourvillier B, Troche G, Reignier J, Dumay MF, Azoulay E, Reignier B, Carlet J, Soufir L (2010) Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Am J Respir Crit Care Med 181:134–142PubMedCrossRefGoogle Scholar
  5. 5.
    Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW (2005) The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 33:1694–1700PubMedCrossRefGoogle Scholar
  6. 6.
    Needham DM, Sinopoli DJ, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, Morlock LL, Makary MA, Pronovost PJ (2005) A system factors analysis of “line, tube, and drain” incidents in the intensive care unit. Crit Care Med 33:1701–1707PubMedCrossRefGoogle Scholar
  7. 7.
    Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC (2010) Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care 22:151–161PubMedCrossRefGoogle Scholar
  8. 8.
    Moreno RP, Rhodes A, Donchin Y (2009) Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med 35:1667–1672PubMedCrossRefGoogle Scholar
  9. 9.
    Naveh E, Katz-Navon T, Stern Z (2011) The effect of safety management systems on continuous improvement of patient safety: the moderating role of safety climate and autonomy. Qual Manage J 18:54–67Google Scholar
  10. 10.
    Katz-Navon T, Naveh E, Stern Z (2005) Safety climate in health care organizations: a multidimensional approach. Acad Manage J 48:1075–1089CrossRefGoogle Scholar
  11. 11.
    Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L (2009) Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care 47:23–31PubMedCrossRefGoogle Scholar
  12. 12.
    Beus JM, Payne SC, Bergman ME, Arthur W (2010) Safety climate and injuries: an examination of theoretical and empirical relationships. J Appl Psychol 95:713–727PubMedCrossRefGoogle Scholar
  13. 13.
    Zohar D (2000) A group-level model of safety climate: testing the effect of group climate on microaccidents in manufacturing jobs. J Appl Psychol 85:587–596PubMedCrossRefGoogle Scholar
  14. 14.
    Flin R (2006) Erosion of managerial resilience: from Vasa to NASA. In: Hollnagel E, Woods DD, Leveson N (eds) Resilience Engineering: concepts and precepts. Ashgate, Farnham, pp 223–233Google Scholar
  15. 15.
    Flin R, O’Connor P, Crichton M (2008) Safety at the sharp end. A guide to non-technical skills. Ashgate, FarnhamGoogle Scholar
  16. 16.
    Woods DD (2006) Essential characteristics of resilience. In: Hollnagel E, Woods DD, Leveson N (eds) Resilience Engineering: concepts and precepts. Ashgate, Farnham, pp 21–34Google Scholar
  17. 17.
    Reis Miranda D, Moreno R, Iapichino G (1997) Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med 23:760–765PubMedCrossRefGoogle Scholar
  18. 18.
    (EUNetPaS) ENfPS, (2010) EUNetPas publication of safety culture instruments used in EU-member states;
  19. 19.
    Singer SJ, Meterko M, Baker L, Gaba DM, Falwell A, Rosen A (2007) Workforce perceptions of hospital safety culture: development and validation of the Patient Safety Climate in Healthcare Organizations survey. Health Serv Res 42:1999–2021PubMedCrossRefGoogle Scholar
  20. 20.
    Colla JB, Bracken AC, Kinney LM, Weeks WB (2005) Measuring patient safety climate: a review of surveys. Qual Saf Health Care 14:364–366PubMedCrossRefGoogle Scholar
  21. 21.
    Flin R, Burns C, Mearns K, Yule S, Robertson EM (2006) Measuring safety climate in health care. Qual Saf Health Care 15:109–115PubMedCrossRefGoogle Scholar
  22. 22.
    Hofmann DA, Mark B (2006) An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. Pers Psychol 59:847–869CrossRefGoogle Scholar
  23. 23.
    Singer S, Lin S, Falwell A, Gaba D, Baker L (2009) Relationship of safety climate and safety performance in hospitals. Health Serv Res 44:399–421PubMedCrossRefGoogle Scholar
  24. 24.
    Zohar D (2002) Modifying supervisory practices to improve subunit safety: a leadership-based intervention model. J Appl Psychol 87:156–163PubMedCrossRefGoogle Scholar
  25. 25.
    Steyrer J, Latzke M, Pils K, Vetter E, Strunk G (2011) Development and validation of a patient safety culture questionnaire in acute geriatric units. Gerontology 57:481–489PubMedCrossRefGoogle Scholar
  26. 26.
    Browne MW, Cudeck R (1993) Alternative ways of assessing equation model fit. In: Bollen K, Long JS (eds) Testing Structural Equation Models. Sage, Newbury Park, pp 136–162Google Scholar
  27. 27.
    Lütticke J, Pfaff H (2002) Wissenschaftliche Grundlagen für ein erweitertes Risiko-Management im Krankenhaus (GERM-Studie). Sozialmedizin und Sozialhygiene der Universität zu Köln, Köln, Abteilung Medizinische Soziologie des Institutes für ArbeitsmedizinGoogle Scholar
  28. 28.
    Rasbash J, Charlton C, Browne WJ, Healy M, Cameron B, (2005) MLwiN Version 2.02. Centre for Multilevel Modelling, University of Bristol, BristolGoogle Scholar
  29. 29.
    Kane-Gill SL, Jacobi J, Rothschild JM (2010) Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med 38:S83–S89PubMedCrossRefGoogle Scholar
  30. 30.
    Camire E, Moyen E, Stelfox HT (2009) Medication errors in critical care: risk factors, prevention and disclosure. CMAJ 180:936–943PubMedGoogle Scholar
  31. 31.
    Valentin A, Bion J (2007) How safe is my intensive care unit? An overview of error causation and prevention. Curr Opin Crit Care 13:697–702PubMedCrossRefGoogle Scholar
  32. 32.
    Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27:183–213CrossRefGoogle Scholar
  33. 33.
    Reason JT (1997) Managing the risk of organisational accidents. Ashgate, LondonGoogle Scholar
  34. 34.
    Ramanujam R, Rousseau DM (2006) The challenges are organizational not just clinical. J Organ Behav 27:811–827CrossRefGoogle Scholar
  35. 35.
    Loukopoulos LD, Dismukes RK, Barshi I (2009) The multitasking myth: handling complexity in real-world operations. Ashgate, FarnhamGoogle Scholar
  36. 36.
    Reason JT (1990) Human error. Cambridge University Press, CambridgeCrossRefGoogle Scholar
  37. 37.
    Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO (2010) Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 170:683–690PubMedCrossRefGoogle Scholar
  38. 38.
    Byrnes MC, Schuerer DJ, Schallom ME, Sona CS, Mazuski JE, Taylor BE, McKenzie W, Thomas JM, Emerson JS, Nemeth JL, Bailey RA, Boyle WA, Buchman TG, Coopersmith CM (2009) Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 37:2775–2781PubMedCrossRefGoogle Scholar
  39. 39.
    Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Moniz T, Rothschild JM, Kachalia AB, Hayes J, Churchill WW, Lipsitz S, Whittemore AD, Bates DW, Gandhi TK (2010) Effect of bar-code technology on the safety of medication administration. N Engl J Med 362:1698–1707PubMedCrossRefGoogle Scholar
  40. 40.
    Cooper JB, Blum RH, Carroll JS, Dershwitz M, Feinstein DM, Gaba DM, Morey JC, Singla AK (2008) Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program. Anesth Analg 106:574–584PubMedCrossRefGoogle Scholar
  41. 41.
    Reader TW, Flin R, Mearns K, Cuthbertson BH (2007) Interdisciplinary communication in the intensive care unit. Br J Anaesth 98:347–352PubMedCrossRefGoogle Scholar
  42. 42.
    Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G (2012) Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units. Health Care Manage Rev. doi: 10.1097/HMR.0b013e318272935a PubMedGoogle Scholar
  43. 43.
    Garrouste Orgeas M, Timsit JF, Soufir L, Tafflet M, Adrie C, Philippart F, Zahar JR, Clec’h C, Goldran-Toledano D, Jamali S, Dumenil AS, Azoulay E, Carlet J (2008) Impact of adverse events on outcomes in intensive care unit patients. Crit Care Med 36:2041–2047PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2012

Authors and Affiliations

  • Andreas Valentin
    • 1
  • Michael Schiffinger
    • 2
  • Johannes Steyrer
    • 2
  • Clemens Huber
    • 2
  • Guido Strunk
    • 3
    • 4
  1. 1.General and Medical ICURudolfstiftung HospitalViennaAustria
  2. 2.Research Institute for Health Care Management and Health Care EconomicsVienna University of Economics and BusinessViennaAustria
  3. 3.Complexity-ResearchViennaAustria
  4. 4.Department of Business Administration and Economic EducationUniversity of TechnologyDortmundGermany

Personalised recommendations