Errors in intensive care units: medical staff report fewer unintended events than observers

A study has shown that the rate of "unintended events" (UE) reporting by intensive care unit (ICU) staff is less than half that of a neutral observer. ICU staff also report different types of UEs compared to observers. In intensive care units, unintended events, often caused by human error, could lead to critical and even fatal incidents in patient care. The authors of the study, published today in the Open Access journal BMC Emergency Medicine, state that observers could be used in ICUs to monitor and report unintended events and other valuable information key to the treatment of patients, which otherwise go undetected or unreported by ICU staff on a daily basis.

It is thought that the rate at which unintended events occur in ICUs can be used as a measure of the quality of care provided. In hospitals, UEs are recorded and assessed using a uniform, international system called the Critical Incident Reporting (CIR) system. However, this system does not provide an objective numerator (the observed number of unintended events) and there is no unequivocal denominator (the number of incident opportunities). In a previous study, it was shown that ICU staff reported only 61% of the errors that were detected by an external observer. These differences may represent a patient safety problem in intensive care units, and if so the size of this problem would be unknown.

In order to compare the rates at which unintended events were reported by ICU staff and impartial observers, Maurizia Capuzzo and colleagues, from the University Hospital of Ferrara, Italy, collected data from two 4-bed, multidisciplinary ICUs in a major hospital. The UEs reported by ICU staff over a fourteen-day period were compared to those recorded by observers, over a consecutive fourteen-day period. The observers had no duties other than to observe and record UEs. An error was defined as an unintended event that reduced or could have reduced the safety margin for the patient whilst in intensive care. UEs were classified according to six different types and four levels of severity.

The rate of UEs per 100 days (the total number of hours spent by each patient in the ICU divided by 24) was 20.3 according to the ICU staff and 53.1 according to the observers. Also, the incidences of five types of UE recorded by the observers were significantly different from those recorded by staff over the whole study period.

According to the study authors, "the ultimate goal of incident reporting is to implement strategies to prevent recurrence. Therefore, to ensure that relevant targets for change are recognised, it is essential to know the reliability of staff reporting". This study demonstrated that ICU staff underestimate the occurrence and types of unintended events. The implication of this study, of general value to the quality and safety of patient care in ICUs, is that invaluable information about incidents in ICUs can be obtained in a short period of time by the use of observer monitoring.

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