Human errors in a multidisciplinary intensive care unit: a 1-year prospective study

Objectives: To determine the incidence and identify risk factors of critica l incidents in an ICU. Design: Prospective observational study of consecutive patients admit ted o ver 1 year to an ICU. Critical incidents were recorded using predefined cri teria. Their causes and consequences were analysed. The causes were classif ied as technical failure, patient's underlying disease, or human errors (su bclassified as planning, execution, or surveillance). The consequences were classified as lethal, leading to sequelae, prolonging the ICU stay, minor, or without consequences. The correlation between critical incidents and sp ecific factors including patient's diagnosis and severity score, use of mon itoring and therapeutic modalities was analysed by uni- and multivariate an alysis. Setting: An 11-bed multidisciplinary ICU in a non-university teaching hospi tal. Patients: 1024 consecutive patients admitted to the ICU. Intervention: None. Measurements and main results: The median length of ICU stay by the 1024 pa tients was 1.9 days. Of the 777 critical incidents reported 2% were due to technical failure and 67% to secondary to underlying disease. There were 24 1 human errors (31%) in 161 patients, evenly distributed among planning (n = 75), execution (n = 88), and surveillance (n = 78). One error was lethal, two led to sequelae, 26% prolonged ICU stay, and 57% were minor and 16% wi thout consequence. Errors with significant consequences were related mainly to planning. Human errors prolonged ICU stay by 425 patient-days, amountin g to 15% of ICU time. Readmitted patients had more frequent and more severe critical incidents than primarily admitted patients. Conclusions: Critical incidents add morbidity, workload, and financial burd en. A substantial proportion of them are related to human factors with dire consequences. Efforts must focus on timely, appropriate care to avoid plan ning and execution mishaps at the beginning of the ICU stay; surveillance i ntensity must be maintained, specially after the fourth day.