The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care
The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care
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DOI：
10.1097/01.ccm.0000171609.91035.bd
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发表时间：
2005-08-01
影响因子：
8.8
通讯作者：
Bates, DW
中科院分区：
文献类型：
--
作者：
Rothschild, JM;Landrigan, CP;Bates, DW
目的：危重症患者需要高强度的护理，并且由于病情严重，医源性损伤的风险可能特别高。我们试图研究重症监护环境中不良事件和严重错误的发生率和性质。设计：我们进行了一项为期1年的前瞻性观察研究。事件收集使用多方面的方法，包括直接连续观察。两名医生独立评估了事件类型、严重程度和可预防性，以及系统相关和个人性能故障。环境：学术性三级保健城市医院。病人：医疗加护病房和冠状动脉护理病房的病人。干预措施:没有。测量方法和主要结果：研究的主要结局是不良事件和严重错误的发生率和比率（每1000患者日）。在1490患者日期间，共研究了391名420单位入院的患者。我们在79例患者中发现120例不良事件（20.2%），其中66例（55%）不可预防，54例（45%）可预防，223例严重不良事件。错误。所有不良事件、可预防不良事件和严重错误的发生率分别为每1000患者日80.5、36.2和149.7。在不良事件中，13%（16/120）危及生命或致命；在严重错误中，11%（24/223）可能危及生命。最严重的医疗差错发生在订购或执行治疗，特别是药物治疗期间（61%;170/277）。绩效层面的失误最常见的是失误和失误（53%;148/277），而不是基于规则或知识的错误。结论：危重患者的不良事件和严重错误是常见的，往往可能危及生命。虽然发现了许多类型的错误，但未能正确执行预期治疗是主要类别。
Objective: Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting.Design: We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures.Setting: Academic, tertiary-care urban hospital.Patients: Medical intensive care unit and coronary care unit patients.Interventions: None.Measurements and Main Results: The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious. errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/277), rather than rule-based or knowledge-based mistakes.Conclusions: Adverse events and serious errors involving-critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category.