ICU Patients at Significant Risk for Adverse Events, Serious Errors

Patients face a significant risk for preventable adverse events and serious medical errors in hospital critical care units, according to a study sponsored by the Agency for Healthcare Research and Quality. The study, The Critical Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care, was published in the August issue of Critical Care Medicine.

Researchers found that more than 20 percent of the patients admitted to two intensive care units at an academic hospital, a medical intensive care unit (MICU) and a coronary critical care unit (CCU), experienced an adverse event. Because these patients are among the sickest, they may be more vulnerable to errors in care, and therefore more susceptible to injury. Of the adverse events in the sample, almost half (45 percent) of them were preventable. A significant number of the adverse events involved medicationsmost commonly, giving patients the wrong dose. Over 90 percent of all incidents occurred during routine care, not on admission or during an emergency intervention.

Even though this is a small study, it demonstrates the potential for harm in our critical care units in a dramatic way, said AHRQ Director Carolyn M. Clancy, MD. These findings are another call to action in our efforts to reduce medical errors and improve patient safety.

The researchers conducted direct continuous observations in the MICU and CCU during nine three-week periods, distributed throughout 12 months from July 2002 through June 2003. This was supplemented by confidential incident reporting, a computerized adverse drug event detection monitor and chart reviews.

According to lead study author Jeffrey M. Rothschild, MD, MPH, critical care units provide an increasingly greater proportion of care. During our lifetimes, we can expect to be admitted to an ICU at least once. We hope these findings will stimulate the adoption of known interventions, like ensuring hand washing, better physician/nurse communications, and greater use of health IT, he said.

Source: Agency for Healthcare Research and Quality (AHRQ)