An analysis of near misses identified by anesthesia providers in the intensive care unit

BMC Anesthesiology

Michael A. Gropper¹  David L. Robinowitz¹  James E. Caldwell¹  Angela K.M. Lipshutz¹ 

[1]Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco 94143, CA, USA

关键词: Airway management;    Critical care anesthesiology;    Critical care;    Near miss;    Adverse event;    Incident reporting;   

Others  :  1215976
DOI  :  10.1186/s12871-015-0075-z

 received in 2014-11-18, accepted in 2015-06-09,  发布年份 2015

【 摘 要 】

Background

Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations.

Methods

We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations.

Results

A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02).

Conclusions

A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.

【 授权许可】

   
2015 Lipshutz et al.

【 图 表 】

Fig. 1.

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