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Medical errors appear to be common among ICU patients, and a simple blame-free reporting system can help identify them

A study of an intensive care unit (ICU) at an urban teaching hospital found medical errors to be common among ICU patients. During a 6-month period in 2003, the SAFE reporting system recorded 232 medical events (ranging from risky situations and near-misses to harmful events) involving 147 patients (89 medical events per 1,000 ICU days). The SAFE reporting system, which enlisted health care providers to voluntarily provide information on errors without being punished for them, described statistically more medical events than a hospital-wide computer database for cataloging errors and high-risk events.

Over half (56 percent) of the errors occurred within the ICU and involved patient care providers working directly in the ICU area. Errors ranged from unrecognized failure of a mechanical ventilator to complications of intravenous medications. Nearly 44 percent of medical errors were commissions or omissions that occurred outside of the ICU during patient transport or in the emergency department and hospital floors. Ten percent of medical events leading to medical errors resulted in the need for additional life-sustaining treatment, and 3 percent may have contributed to patient deaths.

An anonymous report, a simple two-sided card placed at several hospital sites, was not used to assign blame or punish individuals for any reported medical events. The card identified the patient, the event, perceived cause of the event, and whether any action was taken to remedy the situation, as well as the reporting person's job description and optional contact information.

The goal of the SAFE system is to identify the cause of medical errors in order to reduce them in the future, according to the researchers. In the study, which was supported in part by the Agency for Healthcare Research and Quality (HS11898), researchers used the SAFE reporting system to determine the frequency and type of medical errors occurring in the ICU over a 6-month period.

See "Reporting of medical errors: An intensive care unit experience," by Stephen Osmon, M.D., Carolyn B. Harris, M.P.H., W. Claiborne Dunagan, M.D., and others, in Critical Care Medicine 32(3), pp. 727-733, 2004.

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