Review of patient safety incidents reported from critical care units in 2009 and 2010

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Intravenous literature: Thomas, A.N. and Taylor, R.J. (2012) Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Anaesthesia. 16 April [epub ahead of print].

Summary:

We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127 467 calendar days of critical care with a median (IQR [range]) of 31 (26–45 [20–57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7–13 [3.5–27]) incidents per 1000 days were associated with harm. Pressure sores were the most common cause of harm, with a median (IQR [range]) of 3.9 (1.0–6.6 [0–20.4]) incidents per 1000 days. Only 89 (2.1%) incidents described more than temporary harm, of which 12 were airway related incidents. Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced.

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