Tadashi Kamio1,2, Ken Masamune2. 1. Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan. tadashi-kamio@mail.goo.ne.jp. 2. Joint Graduate School of Tokyo Women's Medical University and Waseda University Cooperative Major in Advanced Biomedical Sciences, Tokyo, Japan.
Abstract
BACKGROUND: Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. METHODS: Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made. RESULTS: We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting. CONCLUSIONS: Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists.
BACKGROUND: Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. METHODS: Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made. RESULTS: We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting. CONCLUSIONS:Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists.
Authors: Wai-Tat Wong; Anna Lee; Charles David Gomersall; Lam-Hin Shek; Alfred Chan; Sheung-On So; Kai-Cheuk Sin; Wai-Ming Tang; Maria Sinn; Lowell Ling Journal: BMJ Open Date: 2021-12-30 Impact factor: 2.692