University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia.
Institute for Patient Safety, University Hospital Bonn, Venusberg-Campus-1, 53127, Bonn, Germany.
BMC Health Serv Res. 2024 Jan 16;24(1):77. doi: 10.1186/s12913-024-10544-9.
Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system.
We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021.
A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2).
The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.
医院内发生的不良事件(AEs)仍然是一个全球性的挑战,尤其是在重症监护病房(ICUs)中,不良事件更容易发生。对 AEs 的监测可以深入了解患者安全的现状和进展。本研究旨在检查实施不良事件报告系统后 20 个月内报告的不良事件。
我们对一个自愿的 ICU 不良事件报告系统进行了回顾性分析。事件由突尼斯 Sahloul 大学医院的十家 ICU 的工作人员报告,报告时间为 2020 年 2 月至 2021 年 9 月。
共收到 265 份报告,其中 61.9%被认为是可预防的。报告最多的事件是医源性感染(30.2%,n=80),其次是压疮(18.5%,n=49)。在报告时,有 25 名患者(9.4%)因不良事件死亡,51.3%的情况下,该事件导致住院时间延长。提供者相关因素导致 64.2%的事件,而患者相关因素导致 53.6%的事件。就严重性而言,34.3%的事件(n=91)为不可接受(c3),36.3%的事件(n=96)为“控制下可接受”(c2)。
该报告系统提供了关于 ICU 中发生的不良事件及其后果的特征的丰富信息,因此可能有助于设计有效的、基于证据的干预措施,以减少不良事件的发生。