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October 3, 1980JAMA125 citations

Adverse Occurrences in Intensive Care Units

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NANorman S. Abramson

Key Points

  • Characterize adverse occurrences, their contributing causes, timing, and associated clinical outcomes among patients in an intensive care unit.
  • Analyzed 145 adverse occurrence reports filed in a medical-surgical intensive care unit between 1974 and 1978 (N=145).
  • Evaluated reports for underlying causes (human error vs. equipment malfunction), timing of occurrences, and the presence of bedside staff.
  • Identified 92 instances of human error and 53 cases of equipment malfunction, with a peak incidence between midnight and 1:00 AM.
  • Harm occurred significantly more often when patients were unattended (72%) compared to when they were attended (49%).
  • Mortality was higher in patients with a reported adverse occurrence (41%) than in the general intensive care unit patient population (21%).

Abstract

Analysis of 145 reports of adverse occurrences involving patients in a medical-surgical intensive care unite (ICU), during the yearts 1974 through 1978, disclosed 92 instances of human error and 53 cases of equipment malfunction. A peak occurrence of reported incidents was found between midnight and 1 AM. Harm occurred more frequently if the patient was unattended (72%) than attended (49%) during the incident. Mortality for patients with an incident report filed during their ICU admission (41%) was higher than for all ICU patients (21%). The importance of a well-structured incident-reporting program to minimize problems of human error and device malfunction is stressed.

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Cite This Study

Norman S. Abramson (1980) studied this question.

synapsesocial.com/papers/6a1ffef43224f8dacd0dbcc5https://doi.org/10.1001/jama.1980.03310140040027
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