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Critical Care

, 15:R232

First Online: 29 September 2011Received: 25 May 2011Revised: 28 June 2011Accepted: 29 September 2011


IntroductionIn recent years, critical incident CI reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.

MethodsThe study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit ICU. Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health and safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.

ResultsA total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 30%, clinical practice 257 22.8%, pharmaceuticals 238 21.1%, administration 213 18.9%, health and safety hazards 81 7.2%. The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.

ConclusionsCritical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.

AbbreviationsCIcritical incident

ICUintensive care unit.

Electronic supplementary materialThe online version of this article doi:10.1186-cc10474 contains supplementary material, which is available to authorized users.

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Author: Ingeborg D Welters - James Gibson - Martin Mogk - Richard Wenstone


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