Critical incident reporting in the intensive care unit

• Published in: Anaesthesia Vol. 52; no. 5; pp. 403 - 409
• Main Authors: Buckley, T. A., Short, T. G., Rowbottom, Y. M., Oh, T. E.
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Science Ltd 01-05-1997; Blackwell
• Subjects: Adolescent; Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Child; Child, Preschool; critical incident, quality assurance; Emergency and intensive care: techniques, logistics; Equipment Failure; General aspects; Health and social institutions; Hong Kong; Humans; Intensive care; Intensive care medicine; Intensive care unit. Emergency transport systems. Emergency, hospital ward; Intensive Care Units - standards; Medical Errors; Medical sciences; Monitoring, Physiologic; Program Evaluation; Prospective Studies; Public health. Hygiene; Public health. Hygiene-occupational medicine; Quality Assurance, Health Care; Risk Management - methods; Hong Kong; Asia; Human error; Human; Prevention; Quality assurance; Mishap; Complication; Apparatus failure; Hospital; Public health; Intensive care unit
• ISSN: 0003-2409; 1365-2044
• DOI: 10.1111/j.1365-2044.1997.094-az0085.x

Critical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3‐year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our ‘system’ and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.