Use of a Microprocessor Controlled, Mass Spectrometer Based Monitoring System for Risk Management in a Community Hospital ICU
Recent data has brought to light the significant risk to the patient of respiratory care, even in the best of intensive care units. Perhaps the most provocative and well documented study is that of Abramson et al1. The authors reviewed 145 incident reports generated by their general medical-surgical ICU in a five year period in an effort to determine the nature of adverse occurrences in intensive care. Approximately two-thirds of the adverse occurrences were caused by human error, and the other third by equipment malfunction. In both these categories, respiratory care equipment malfunction or misuse was the leading cause for generation of an incident report. These adverse occurrences resulted in harm to the patient (as defined by the authors) in approximately 48% of the reports; if the patient was unattended, 72% of the incidents resulted in harm to the patient. The authors note that not all incidents are reported, that is, generate an incident report. The true incidence of adverse occurrences in intensive care units therefore remains unknown, but certainly higher than the Pittsburgh group reported. The study confirmed the previous work of Osborn and colleagues2,3, and Zwillich et al4 who also noted a disturbingly high number of adverse occurrences associated with respiratory care and mechanical ventilation.
KeywordsIncident Report Quality Control Program Inspire Oxygen Concentration Respiratory Care Equipment Malfunction
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