Critical incident reporting was introduced into the intensive care unit (ICU) as part of the development of 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 managements 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 iii 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.
Mots-clés Pascal : Unité soin intensif, Incident, Complication, Assurance qualité, Erreur humaine, Défaillance appareil, Prévention, Homme, Hôpital, Hong Kong, Asie
Mots-clés Pascal anglais : Intensive care unit, Mishap, Complication, Quality assurance, Human error, Apparatus failure, Prevention, Human, Hospital, Hong Kong, Asia
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 97-0308599
Code Inist : 002B27B14C. Création : 15/07/1997.