Critical care units put patients at significant risk for adverse events, serious errors

According to a study sponsored by HHS’ Agency for Healthcare Research and Quality (AHRQ) and appearing in a recent issue of Critical Care Medicine, patients face a significant risk for preventable adverse events and serious medical errors in hospital critical care units.

During nine three-week periods, distributed throughout 12 months from July 2002 through June 2003, researchers conducted direct continuous observations in a medical intensive care unit (MICU) and a coronary critical care unit (CCU) at an academic hospital. This was supplemented by confidential incident reporting, a computerized adverse drug event detection monitor and chart reviews.

Researchers found that more than 20% of the patients admitted experienced an adverse event. Because these patients are among the sickest, they may be more vulnerable to errors in care, and therefore more susceptible to injury.

Of the adverse events in the sample, nearly half (45%) of them were preventable. A significant number most commonly involved giving giving patients the wrong dose of medications. Over 90% of all incidents occurred during routine care, not on admission or during an emergency intervention.

AHRQ Director Carolyn M. Clancy, MD said, “Even though this is a small study, it demonstrates the potential for harm in our critical care units in a dramatic way. These findings are another call to action in our efforts to reduce medical errors and improve patient safety.”

According to lead study author Jeffrey M. Rothschild, MD, MPH, critical care units provide an increasingly greater proportion of care. “During our lifetimes, we can expect to be admitted to an ICU at least once,” he pointed out. “We hope these findings will stimulate the adoption of known interventions, like ensuring hand washing, better physician/nurse communications, and greater use of health IT.”

SOURCE: “The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care.” Critical Care Medicine. 33(8):1694-1700, August 2005.