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Adverse events are common on the intensive care unit: results from a structured record review
Division of Drug Research, Anesthesiology and Intensive Care, Department of Medical and Health Sciences, Linköpings university, Linköping, Sweden; Department of Anesthesia and Intensive Care, University Hospital, Linköping, Sweden.
Department of Anesthesia and Intensive Care, Vrinnevi Hospital, Norrköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
Department of Anesthesia and Intensive Care, Vrinnevi Hospital, Norrköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
Department of Anesthesia and Intensive Care, University Hospital, Linköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.ORCID iD: 0000-0001-8549-9039
2012 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 56, no 8, p. 959-965Article in journal (Refereed) Published
Abstract [en]

Background: Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICUduring a 2-year period.

Methods: A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.

Results: We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.

Conclusion: Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.

Place, publisher, year, edition, pages
Hoboken, USA: Wiley-Blackwell, 2012. Vol. 56, no 8, p. 959-965
National Category
Medical and Health Sciences Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:oru:diva-40795DOI: 10.1111/j.1399-6576.2012.02711.xISI: 000307437600003PubMedID: 22571769Scopus ID: 2-s2.0-84865126430OAI: oai:DiVA.org:oru-40795DiVA, id: diva2:778724
Available from: 2012-08-17 Created: 2015-01-11 Last updated: 2018-08-27Bibliographically approved

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