Abstract
Intensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.
Original language | English |
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Pages (from-to) | 314-319 |
Number of pages | 6 |
Journal | Anaesthesia and Intensive Care |
Volume | 24 |
Issue number | 3 |
DOIs | |
Publication status | Published or Issued - Jun 1996 |
Externally published | Yes |
Keywords
- Intensive care: incident monitoring, quality assurance, patient safety
ASJC Scopus subject areas
- Critical Care and Intensive Care Medicine
- Anesthesiology and Pain Medicine