专家从不同角度探索,降低ICU中的医疗错误
Looking at Various Perspectives, Researchers
Seek to Reduce Errors in the ICU
Disclosures
Antonios Liolios, MD
Introduction
Medical errors have recently received international
attention as a cause of excessive and possibly preventable
morbidity and mortality. Errors in the intensive care
unit (ICU) environment play an even greater role, as
minor omissions or deviations from standard therapy
may have dramatic consequences. A panel of critical
care experts evaluated the occurrence of errors in the
ICU and their relation to the ICU organization and to
the presence of an intensivist-directed team.
The
ICU From the Medical Perspective
The
ICU From the Surgical Perspective
The
ICU From the Anesthesia Perspective
The
ICU From the Nursing Perspective
The
ICU From the Pharmacy Perspective
Conclusions
he ICU is an area where patients with complicated
conditions are cared for by multidisciplinary teams
and receive complex and interactive treatment. Errors
do happen in this setting, and it is crucial to develop
an environment of trust that will promote error reporting
and registration. In the complex ICU milieu, errors
do occur mainly because of system failures. Establishing
strategies to improve the system's performance is
crucial.
The direction of the ICU by a dedicated and certified
intensivist helps optimize patient care and even reduce
mortality and cost. Even when an intensivist cannot
be physically present, telemedicine has a favorable
effect on patients' outcomes. Nursing staff shortage
is a growing and serious problem as higher nurse to
patient ratios have been shown to increase mortality
and complications. The pharmacist plays a very important
role in the ICU as his or her regular presence in
ICU rounds as a full ICU member has considerably decreased
prescription errors. Newer technologies substantially
assist in decreasing adverse drug events.
Overall, the ICU is a very sophisticated and exponentially
growing complex environment. It should be kept in
mind, though, that human vigilance and direct physician-patient
interaction are the most important and often overlooked
factors that prevent errors. Despite much improvement,
humans do not go along well with machines. Even with
the newest models of monitoring or drug administering
devices, a human may be easily confused and the patient's
care jeopardized. Spending more time at the bedside
and obtaining a more detailed history are often the
most essential factors that will help prevent an error
or recognize it in time.
References
1. Chalfin D. Panel: errors and safety: ICU organization
on outcomes from the critical illness. Medical perspective.
Program and abstracts of the 32nd Critical Care Congress;
January 28-February 2, 2003; San Antonio, Texas.
2. Leape LL, Brennan TA, Laird N, et al. The nature
of adverse events in hospitalized patients. Results
of the Harvard Medical Practice Study II. N Engl J
Med. 1991;324:377-384.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence
of adverse events and negligence in hospitalized patients.
Results of the Harvard Medical Practice Study I. N
Engl J Med. 1991;324:370-376.
4. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis
of adverse drug events. ADE Prevention Study Group.
JAMA. 1995;274:35-43.
5. Mallick R, Strosberg M, Lambrinos J, et al. The
intensive care unit medical director as manager. Impact
on performance. Med Care. 1995;33:611-624.
6. Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational
characteristics of intensive care units related to
outcomes of abdominal aortic surgery. JAMA. 1999;281:1310-1317.
7. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist
participation on physician rounds and adverse drug
events in the intensive care unit. JAMA. 1999;282:267-270.
8. Lipsett PA. Panel: errors and safety: ICU organization
on outcomes from the critical illness. Surgical perspective.
Program and abstracts of the 32nd Critical Care Congress;
January 28-February 2, 2003; San Antonio, Texas.
9. Ghorra S, Reinert SE, Cioffi W, et al. Analysis
of the effect of conversion from open to closed surgical
intensive care unit. Ann Surg. 1999;229:163-171.
10. Aiken LH, Clarke SP, Sloane DM, et al. Hospital
nurse staffing and patient mortality, nurse burnout,
and job dissatisfaction. JAMA. 2002;288:1987-1993.
11. Dimick JB, Pronovost PJ, Heitmiller RF, et al.
Intensive care unit physician staffing is associated
with decreased length of stay, hospital cost, and
complications after esophageal resection. Crit Care
Med. 2001;29:753-758.
12. Young MP, Birkmeyer JD. Potential reduction in
mortality rates using an intensivist model to manage
intensive care units. Eff Clin Pract. 2000;3:284-289.
13. Pronovost PJ, Angus DC, Dorman T, et al. Physician
staffing patterns and clinical outcomes in critically
ill patients: a systematic review. JAMA. 2002;288:2151-2162.
14. Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive
care unit telemedicine: alternate paradigm for providing
continuous intensivist care. Crit Care Med. 2000;28:3925-3931.
15. Deutschman C. Panel: errors and safety: ICU organization
on outcomes from the critical illness. Anesthesia
perspective. Program and abstracts of the 32nd Critical
Care Congress; January 28-February 2, 2003; San Antonio,
Texas.
16. Hanson CW 3rd, Deutschman CS, Anderson HL 3rd,
et al. Effects of an organized critical care service
on outcomes and resource utilization: a cohort study.
Crit Care Med. 1999;27:270-274.
17. Jastremski C. Panel: errors and safety: ICU organization
on outcomes from the critical illness. Nursing perspective.
Program and abstracts of the 32nd Critical Care Congress;
January 28-February 2, 2003; San Antonio, Texas.
18. Jacobi J. Panel: errors and safety: ICU organization
on outcomes from the critical illness. Pharmacy perspective.
Program and abstracts of the 32nd Critical Care Congress;
January 28-February 2, 2003; San Antonio, Texas.
19. Bates DW, Spell N, Cullen DJ, et al. The costs
of adverse drug events in hospitalized patients. Adverse
Drug Events Prevention Study Group. JAMA. 1997;277:307-311.
20. Pathways for Medication Safety Web site. Available
at: http://www.medpa thways.info. Accessed February
21, 2003.
21. Calabrese AD, Erstad BL, Brandl K, et al. Medication
administration errors in adult patients in the ICU.
Intensive Care Med. 2001;27:1592-1598.
22. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired
medication history in promoting patient safety. Am
J Health Syst Pharm. 2002;59:2221-2225.
|