Valentin Andreas, Capuzzo Maurizia, Guidet Bertrand, Moreno Rui P, Dolanski Lorenz, Bauer Peter, Metnitz Philipp G H
KA Rudolfstiftung, II. Medical Department, Juchgasse 25, 1030 Vienna, Austria.
Intensive Care Med. 2006 Oct;32(10):1591-8. doi: 10.1007/s00134-006-0290-7. Epub 2006 Jul 28.
To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs).
An observational, 24-h cross-sectional study of incidents in five representative categories.
205 ICUs worldwide
Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.
In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7-42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00-1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18-2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04-1.08).
Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.
在多国层面评估重症监护病房（ICU）中影响患者安全的特定意外事件（警讯事件）的发生率及相关因素。
对五个具有代表性类别的事件进行24小时横断面观察性研究。
全球205个ICU
重症监护病房工作人员使用结构化问卷报告事件。评估了与ICU及患者相关的因素。
在1913例成年患者中，共报告了影响391例患者的584起事件。在24小时内，136例患者发生了与用药相关的多重错误；158例患者出现了管路、导管和引流管的意外拔除或不当断开；112例患者出现设备故障；47例患者出现人工气道丢失、阻塞或漏气；17例患者出现警报不当关闭。每100个患者日观察到38.8起（95%置信区间34.7 - 42.9）事件。在以ICU为随机成分的多元逻辑回归分析中，以下因素与发生警讯事件的较高几率相关：任何器官衰竭（比值比1.13，95%置信区间1.00 - 1.28）、护理强度较高（比值比1.62，95%置信区间1.18 - 2.22）以及暴露时间（比值比1.06，95%置信区间1.04 - 1.08）。
ICU中与用药、留置管路、气道及设备故障相关的警讯事件发生频率较高。尽管患者安全在许多ICU中被视为一个严重问题，但迫切需要制定和实施预防及早期发现错误的策略。
