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mistake in ICU

Lowell Ling, Charles David Gomersall, Winnie Samy, Gavin Matthew Joynt, Czarina Ch Leung, Wai-Tat Wong, Anna Lee
BACKGROUND: Patient safety culture is an integral aspect of good standard of care. A good patient safety culture is believed to be a prerequisite for safe medical care. However, there is little evidence on whether general education can enhance patient safety culture. OBJECTIVE: Our aim was to assess the impact of a standardized patient safety course on health care worker patient safety culture. METHODS: Health care workers from Intensive Care Units (ICU) at two hospitals (A and B) in Hong Kong were recruited to compare the changes in safety culture before and after a patient safety course...
2016: Journal of Medical Internet Research
M Kieninger, N Zech, Y Mulzer, S Bele, M Seemann, H Künzig, A Schneiker, M Gruber
BACKGROUND: Point of care testing with blood gas analysis (BGA) is an important factor for intensive care medicine. Continuous efforts to optimize workflow, improve safety for the staff and avoid preanalytical mistakes are important and should reflect quality management standards. AIM: In a prospective observational study it was investigated whether the implementation of a new system for BGA using labeled syringes and automated processing of the specimens leads to improvements compared to the previously used procedure...
May 2015: Der Anaesthesist
Maria Mazurkiewicz-Bełdzińska, Marta Szmuda, Marta Zawadzka, Agnieszka Matheisel
The management of status epilepticus (SE) has changed in recent years. Substantial differences exist regarding the definition and time frame of a seizure, which has been operationally defined as lasting for 5 min. Not only have many new intravenous drugs, such as levetiracetam and lacosamide been introduced but other routes of administration, such as intranasal or buccal administration for midazolam, are also being developed. Optimal and successful therapy initiated at the appropriate moment, adequately tailored to the clinical state of the patient, determines the first step in the normalisation of vital functions and leads to the restoration of the physiological homeostatic mechanisms of the organism...
September 2014: Anaesthesiology Intensive Therapy
Alessandra Negro, Roberta Ranzani, Mariagrazia Villa, Duilio Manara
BACKGROUND: Endotracheal suctioning is a common procedure performed by intensive care nurses in order to establish and maintain gas exchange, adequate oxygenation and alveolar ventilation in critically ill patients under mechanical ventilation. As this procedure is associated with several complications and risks nurses should have an adequate knowledge on how to perform the procedure according to the evidence-based practice. Previously only a few studies have analysed nurses' knowledge of the guidelines on endotracheal suctioning...
December 2014: Intensive & Critical Care Nursing: the Official Journal of the British Association of Critical Care Nurses
Grzegorz Niewiński, Małgorzata Starczewska, Andrzej Kański
The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system is time consuming. The mean time for introducing a patient's data to APACHE IV is 37.3 min. Nevertheless, statisticians have known for years that the higher the number of variables the mathematical model describes, the more accurate the model. Because of the necessity of gathering data over a 24-hour period and of determining one cause for ICU admission, the system is troublesome and prone to mistakes. The evolution of the APACHE scoring system is an example of unfulfilled hopes for accurately estimating the risk of death for patients admitted to the ICU; satisfactory prognostic effects resulting from the use of APACHE II and III have been recently studied in patients undergoing liver transplantations...
January 2014: Anaesthesiology Intensive Therapy
Larissa Chaves Pedreira, Adriana Souza Brandão, Aline Macêdo Reis
This study aims to identify the scientific production in Latin America about the safety of aged people in the ICU and adverse events dealt in the literature. It is a systematic revision, with indexed key words. The inclusion and exclusion criteria were respected. Twenty papers were selected for analysis. Most of them were carried out after the year 2000, in Brazil, by professional nurses and physicians, dealing mostly with adverse events connected to mistakes with medicines, accidental remove of probes and catheters, nosocomial infections, errors in the procedure techniques and occurrence of pressure sores...
May 2013: Revista Brasileira de Enfermagem
Asad Latif, Nishi Rawat, Aliaksei Pustavoitau, Peter J Pronovost, Julius C Pham
OBJECTIVE: To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings. DESIGN: : A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented. SETTING: Hospitals participating in the MEDMARX reporting system. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data...
February 2013: Critical Care Medicine
Marck Htm Haerkens, Donald H Jenkins, Johannes G van der Hoeven
Intensive care frequently results in unintentional harm to patients and statistics don't seem to improve. The ICU environment is especially unforgiving for mistakes due to the multidisciplinary, time-critical nature of care and vulnerability of the patients. Human factors account for the majority of adverse events and a sound safety climate is therefore essential. This article reviews the existing literature on aviation-derived training called Crew Resource Management (CRM) and discusses its application in critical care medicine...
2012: Annals of Intensive Care
T Levent, F Delfosse, F Lambiotte, S Dezorzi, L Gosteau, M Vasseur
OBJECTIVE: The authors had for aim to assess the quality of antibiotic prescription in an intensive care unit because of their high rate of consumption. DESIGN: A prospective 5-month study was made of the first 50 prescriptions of ciprofloxacin, levofloxacin, teicoplanin, vancomycin, and imipenem. Treatment was considered adequate at day 5 if the indication was relevant, with the right doses, and if the prescription was adapted to the antibiogram. RESULTS: Fifty treatments were evaluated (38 patients included)...
July 2012: Médecine et Maladies Infectieuses
Majid M Altuwaijri, Abdullah Bahanshal, Mona Almehaid
OBJECTIVE: The purpose of this study is to describe the needs, process and experience of implementing a computerized physician order entry (CPOE) system in a leading healthcare organization in Saudi Arabia. MATERIALS AND METHODS: The National Guard Health Affairs (NGHA) deployed the CPOE in a pilot department, which was the intensive care unit (ICU) in order to assess its benefits and risks and to test the system. After the CPOE was implemented in the ICU area, a survey was sent to the ICU clinicians to assess their perception on the importance of 32 critical success factors (CSFs) that was acquired from the literature...
September 2011: Journal of Family & Community Medicine
L Olper, L Cabrini, G Landoni, A Rossodivita, L Nobile, G Monti, O Alfieri, A Zangrillo
BACKGROUND: Non-invasive ventilation (NIV) can prevent or treat postoperative acute respiratory failure. NIV after discharge from the Intensive Care Unit (ICU) has never been described in the setting of cardiac surgery. METHODS: This study enrolled 85 patients who received NIV in the main ward as treatment for respiratory failure. The patients had the following conditions: atelectasis (45 patients), pleural effusion (20 patients), pulmonary congestion (13 patients), diaphragm hemiparesis (6 patients), pneumonia (4 patients) or a combination of these conditions...
January 2011: Minerva Anestesiologica
Jan-Peter Braun, Hanswerner Bause, Frank Bloos, Götz Geldner, Marc Kastrup, Ralf Kuhlen, Andreas Markewitz, Jörg Martin, Hendrik Mende, Michael Quintel, Klaus Steinmeier-Bauer, Christian Waydhas, Claudia Spies
Critical care medicine frequently involves decisions and measures that may result in significant consequences for patients. In particular, mistakes may directly or indirectly derive from daily routine processes. In addition, consequences may result from the broader pharmaceutical and technological treatment options, which frequently involve multidimensional aspects. The increasing complexity of pharmaceutical and technological properties must be monitored and taken into account. Besides the presence of various disciplines involved, the provision of 24-hour care requires multiple handovers of significant information each day...
2010: German Medical Science: GMS E-journal
M Palomar Martínez, F Alvarez Lerma, M A Riera Badía, C León Gil, M J López Pueyo, C Díaz Tobajas, R Sierra Camerino, L Benítez Ruiz, Y Agra Varela
OBJECTIVE: to assess the applicability on a national level of the interventions proposed by Peter Pronovost et al in Michigan state for the prevention of central vascular catheter-related bacteremia (B-CVC) in patients admitted to the ICU. DESIGN: pilot, prospective and comparative study. SETTING: eighteen ICUs (9 control and 9 intervention) from three autonomous communities in Spain during 3 months in 2007 participated in the study. INTERVENTION: the following activities were included: a) training program for health care personnel, b) introduction of specific measures related to the insertion and care of CVC (catheter insertion checklist, basic recommendations for maintenance of central catheters, dedicated cart for venous accesses, information poster with the five procedures proposed to reduce bacteremias: hands hygiene, use of maximal aseptic barriers during insertion, asepsis of the skin at the insertion point with chlorhexidine, avoidance of the femoral access, and removal of all CVC) and c) measures aiming to promote the culture of safe daily work (daily objectives, learning from mistakes, safety rounds)...
December 2010: Medicina Intensiva
A Miller, D Pilcher, N Mercaldo, T Leong, C Scheinkestel, J Schildcrout
BACKGROUND: Screen designs in computerized clinical information systems (CIS) have been modeled on their paper predecessors. However, limited understanding about how paper forms support clinical work means that we risk repeating old mistakes and creating new opportunities for error and inefficiency as illustrated by problems associated with computerized provider order entry systems. PURPOSE: This study was designed to elucidate principles underlying a successful ICU paper-based CIS...
August 2010: Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses
Paulo de Oliveira Vasconcelos Filho, Maria José Carvalho Carmona, José Otávio Costa Auler Júnior
BACKGROUND AND OBJECTIVES: Elderly patients have their own physiologic characteristics, and sometimes may have organic deficits or severe diseases, which by themselves may complicate the postoperative period. This article is aimed at reviewing post-cardiac surgery procedures in the elderly, describing their most frequent problems. CONTENTS: Elderly patients intraoperative approaches should be decided taking into account lower postoperative morbidity. At ICU arrival, the same criteria for other adult patients of cardiac surgeries should be adopted to maintain service standardization and routine, thus preventing mistakes...
October 2004: Revista Brasileira de Anestesiologia
Steven Q Simpson, Douglas A Peterson, Amy R O'Brien-Ladner
Hospitals, especially their intensive care units, are not particularly safe for patients. Life-threatening mistakes and omissions in care can and do occur. To deter omissions and mistakes wherever possible, our medical intensive care team developed a checklist of care issues that must be addressed daily for every patient in our intensive care unit. The checklist augments our daily, multidisciplinary quality rounds and informs all personnel when important items have been missed. It is too soon to tell whether the checklist has had an impact on our survival rate or length of stay, but we have documented clear improvement in our attention to these core intensive care issues...
April 2007: AACN Advanced Critical Care
I Parviainen, S M Jakob, M Suistomaa, J Takala
BACKGROUND: Physiological data obtained with the pulmonary artery catheter (PAC) are susceptible to errors in measurement and interpretation. Little attention has been paid to the relevance of errors in hemodynamic measurements performed in the intensive care unit (ICU). The aim of this study was to assess the errors related to the technical aspects (zeroing and reference level) and actual measurement (curve interpretation) of the pulmonary artery occlusion pressure (PAOP). METHODS: Forty-seven participants in a special ICU training program and 22 ICU nurses were tested without pre-announcement...
May 2006: Acta Anaesthesiologica Scandinavica
J Gonzalez-Bermejo, V Laplanche, F E Husseini, A Duguet, J-P Derenne, T Similowski
The home ventilator market has grown in size and complexity. The aim of this study was to determine if common home ventilators are user-friendly for trained intensive care unit (ICU) physicians. Eleven ventilator models were tested by 13 ICU physicians without practical experience in home mechanical ventilation. Six tests were defined (start-up, unlocking, mode and setting recognition, mode change, pressure setting and alarm). For each test, the physicians were timed and their performance compared with a reference time established by a technician...
June 2006: European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology
Anne S Rabert, Mary Molly C Sebastian
Based on overwhelming scientific evidence, The Leapfrog Group focused on 3 practices that have tremendous potential to save lives by reducing preventable mistakes in hospitals. The authors describe these practices and how they served as a driving force to create a "virtual ICU" within a Magnet hospital network. The effort combined services of a board-certified intensivist and technological advancements in telemedicine to ensure the delivery of high-quality care to all critically ill patients throughout the network...
January 2006: Journal of Nursing Administration
Bernd Hartmann, Jochen Sucke, Dominik Brammen, Andreas Jost, Alexander Eicher, Rainer Röhrig, Axel Junger
Within surgical departments, a large amount of antibiotics is used for perioperative prophylaxis. Despite the existence of several guidelines and recommendations for administering antibiotic prophylaxis, mistakes still do occur and have an unknown impact on outcome severity. Based on the electronic anaesthesia records of 4304 patients undergoing defined surgical procedures requiring perioperative antibiotic prophylaxis, a matched pairs approach was used to evaluate the impact of inadequate antibiotic prophylaxis on hospital mortality and prolonged length of stay on intensive care...
March 2005: International Journal of Antimicrobial Agents
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