CRITICAL INCIDENT REPORTING IN THE INTENSIVE-CARE UNIT

Critical incident reporting was introduced into the intensive care uni t (ICU) as part of the development of a quality assurance programme wi thin our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of c ritical incidents were sought. Detection of a critical incident in ove r 50% of cases resulted from direct observation of the patient while m onitoring systems accounted for a further 27%. No physiological change s were observed in 54% of critical incidents. The most common incident s reported concerned airway management and invasive lines, tubes and d rains. Human error was a factor in 55% of incidents while violations o f standard practice contributed to 28%. Critical incident reporting wa s 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 i n our quality assurance programme. Improvements in quality of care fol lowing implementation of preventative strategies await further assessm ent.