Ángela Alonso-Ovies1, Nicolás Nin2, Maria Cruz Martín3, Federico Gordo4, Paz Merino5, José M Añón6, Blanca Obón7, Mónica Magret8, Isabel Gutiérrez7. 1. Department of Intensive Care Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain. Electronic address: a.alonso@salud.madrid.org. 2. Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay. 3. Department of Intensive Care Medicine, Hospital Universitario de Torrejón, Madrid, Spain. 4. Department of Intensive Care Medicine, Hospital Universitario del Henares, Coslada, Madrid, Spain. 5. Department of Intensive Care Medicine, Hospital Can Misses, Ibiza, Spain. 6. Department of Intensive Care Medicine, Hospital Universitario La Paz-Carlos III, IdiPAZ, CIBERES, Instituto de Salud Carlos III, Madrid, Spain. 7. Department of Intensive Care Medicine, Hospital Clínico, Zaragoza, Spain. 8. Department of Intensive Care Medicine, Hospital Universitario Joan XXIII, Tarragona, Spain.
Abstract
PURPOSE: To assess incidence, related factors and characteristics of safety incidents associated with the whole process of airway management and mechanical ventilation (MV) in Spanish ICUs. MATERIALS AND METHODS: Observational, prospective, 7 days cross-sectional multicenter study. Airway and MV related incidents were reported using structured questionnaire. Type, characteristics, severity, avoidability and contributing factors of the incidents were assessed. RESULTS: Participant ICUs: 104. Inclusion of 1267 patients; 745 (59%) suffered one or more incidents. Incidents reported: 2492 (59% non-harm-events, 41% adverse events). Individual risk of suffering at least one incident: 66.6%. Incidence ratio (median) of incidents: 2 per 100 patient-hours. 73.7% of incidents were related to MV process, 9.5% to tracheostomy, 6.2% to non-invasive MV, 5.4% to weaning/extubation, 4.4% to intubation and 0.8% to prone position. Temporary damage was produced in 12% incidents, while 0.8% was related to permanent injuries, risk to the patient's life or contributed to death. Incidents were considered avoidable in 73.5% of cases. 98% of all incidents had 1 or more contributing factors. CONCLUSIONS: MV is a risk process in critical patients. Although most incidents did not harm patients, some caused damage and a few were related to the patient's death or permanent damage. Preventability is high.
PURPOSE: To assess incidence, related factors and characteristics of safety incidents associated with the whole process of airway management and mechanical ventilation (MV) in Spanish ICUs. MATERIALS AND METHODS: Observational, prospective, 7 days cross-sectional multicenter study. Airway and MV related incidents were reported using structured questionnaire. Type, characteristics, severity, avoidability and contributing factors of the incidents were assessed. RESULTS:Participant ICUs: 104. Inclusion of 1267 patients; 745 (59%) suffered one or more incidents. Incidents reported: 2492 (59% non-harm-events, 41% adverse events). Individual risk of suffering at least one incident: 66.6%. Incidence ratio (median) of incidents: 2 per 100 patient-hours. 73.7% of incidents were related to MV process, 9.5% to tracheostomy, 6.2% to non-invasive MV, 5.4% to weaning/extubation, 4.4% to intubation and 0.8% to prone position. Temporary damage was produced in 12% incidents, while 0.8% was related to permanent injuries, risk to the patient's life or contributed to death. Incidents were considered avoidable in 73.5% of cases. 98% of all incidents had 1 or more contributing factors. CONCLUSIONS: MV is a risk process in critical patients. Although most incidents did not harm patients, some caused damage and a few were related to the patient's death or permanent damage. Preventability is high.