Lipshutz Angela K M, Caldwell James E, Robinowitz David L, Gropper Michael A
Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
BMC Anesthesiol. 2015 Jun 17;15:93. doi: 10.1186/s12871-015-0075-z.
Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations.
We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations.
A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02).
A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
从不良事件和未遂失误中吸取教训可能会降低可预防错误的发生率。目前关于重症监护病房（ICU）不良事件和未遂失误的文献主要关注护士和重症监护医生报告的错误。麻醉人员识别出的ICU未遂失误可能会揭示其他人员未发现的关键事件、因果机制和系统弱点，并且在特征和因果关系上可能与其他麻醉场所的未遂失误有所不同。
我们分析了2009年至2011年期间报告给我们麻醉未遂失误报告系统的事件。我们将ICU未遂失误的因果机制与其他麻醉场所的未遂失误进行了比较。
共报告了1811起未遂失误，其中22起（1.2%）发生在ICU。五种因果机制解释了一半以上的ICU未遂失误。与其他场所的未遂失误相比，ICU的未遂失误在值班时更易发生（45%对19%，p = 0.001），并且更可能与气道管理相关（50%对12%，p < 0.001）。ICU未遂失误与设备问题相关的可能性较小（23%对48%，p = 0.02）。
少数因果机制解释了大多数ICU未遂失误，为质量改进提供了目标。与ICU气道管理相关的错误可能未得到充分认识。专科顾问可以识别重症监护人员未发现的系统弱点，并且应该参与到ICU患者安全行动中来。
