Abstract
Purpose
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.
Methods
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.
Results
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).
Conclusions
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.
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References
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:c309
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:b814
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 32:1591–1598
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 181:134–142
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 33:1694–1700
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 33:1701–1707
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 22:151–161
Moreno RP, Rhodes A, Donchin Y (2009) Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med 35:1667–1672
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 18:54–67
Katz-Navon T, Naveh E, Stern Z (2005) Safety climate in health care organizations: a multidimensional approach. Acad Manage J 48:1075–1089
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 47:23–31
Beus JM, Payne SC, Bergman ME, Arthur W (2010) Safety climate and injuries: an examination of theoretical and empirical relationships. J Appl Psychol 95:713–727
Zohar D (2000) A group-level model of safety climate: testing the effect of group climate on microaccidents in manufacturing jobs. J Appl Psychol 85:587–596
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 223–233
Flin R, O’Connor P, Crichton M (2008) Safety at the sharp end. A guide to non-technical skills. Ashgate, Farnham
Woods DD (2006) Essential characteristics of resilience. In: Hollnagel E, Woods DD, Leveson N (eds) Resilience Engineering: concepts and precepts. Ashgate, Farnham, pp 21–34
Reis Miranda D, Moreno R, Iapichino G (1997) Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med 23:760–765
(EUNetPaS) ENfPS, (2010) EUNetPas publication of safety culture instruments used in EU-member states; http://www.eunetpas.eu/
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 42:1999–2021
Colla JB, Bracken AC, Kinney LM, Weeks WB (2005) Measuring patient safety climate: a review of surveys. Qual Saf Health Care 14:364–366
Flin R, Burns C, Mearns K, Yule S, Robertson EM (2006) Measuring safety climate in health care. Qual Saf Health Care 15:109–115
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 59:847–869
Singer S, Lin S, Falwell A, Gaba D, Baker L (2009) Relationship of safety climate and safety performance in hospitals. Health Serv Res 44:399–421
Zohar D (2002) Modifying supervisory practices to improve subunit safety: a leadership-based intervention model. J Appl Psychol 87:156–163
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 57:481–489
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 136–162
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 Arbeitsmedizin
Rasbash J, Charlton C, Browne WJ, Healy M, Cameron B, (2005) MLwiN Version 2.02. Centre for Multilevel Modelling, University of Bristol, Bristol
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–S89
Camire E, Moyen E, Stelfox HT (2009) Medication errors in critical care: risk factors, prevention and disclosure. CMAJ 180:936–943
Valentin A, Bion J (2007) How safe is my intensive care unit? An overview of error causation and prevention. Curr Opin Crit Care 13:697–702
Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27:183–213
Reason JT (1997) Managing the risk of organisational accidents. Ashgate, London
Ramanujam R, Rousseau DM (2006) The challenges are organizational not just clinical. J Organ Behav 27:811–827
Loukopoulos LD, Dismukes RK, Barshi I (2009) The multitasking myth: handling complexity in real-world operations. Ashgate, Farnham
Reason JT (1990) Human error. Cambridge University Press, Cambridge
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 170:683–690
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 37:2775–2781
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 362:1698–1707
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 106:574–584
Reader TW, Flin R, Mearns K, Cuthbertson BH (2007) Interdisciplinary communication in the intensive care unit. Br J Anaesth 98:347–352
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
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 36:2041–2047
Acknowledgments
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.
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Valentin, A., Schiffinger, M., Steyrer, J. et al. Safety climate reduces medication and dislodgement errors in routine intensive care practice. Intensive Care Med 39, 391–398 (2013). https://doi.org/10.1007/s00134-012-2764-0
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DOI: https://doi.org/10.1007/s00134-012-2764-0