icu

The ICU From the Medical Perspective
　　Donald Chalfin, MD, MS,[1] of Maimonides Medical Center in Brooklyn, New York, reviewed errors in the ICU from the medical perspective.
　　Errors happen often in the medical environment. Approximately 1 of 3 hospitalized patients will suffer from some form of medical error. These errors are up to 70% preventable; and specifically, adverse drug errors may be prevented in more than 40% of cases. If we consider nosocomial infections a failure to comply with infection control guidelines, it is worrisome to know that they represent the fifth highest cause of hospital death. The report of the Institute of Medicine is also very distressing: based on 2 reports by Leape and Brennan and colleagues,[2,3] and after extrapolating the results to the more than 33.6 million admissions to US hospitals in 1997, it was inferred that at least 44,000 and perhaps as many as 98,000 patients die in US hospitals each year as a result of medical errors.
　　Although there are no clear boundaries between "medical" and other types of iatrogenic errors, medicine has some special characteristics. It involves inpatient and outpatient care, multiple specialty consultants, more adverse drug events, and occasionally the practice of defensive medicine.
　　There is a tendency today to move away from the individual as the center of error prevention and to focus on the system permitting these errors. The "paternalistic," physician-centered system is replaced by system-based responsibility and patient accountability. What is more important is the will of the medical community to accept errors and to work on their prevention instead of denying or concealing them.
　　While the term "iatrogenesis" is widely used to describe medical errors stemming from the physician (deriving from the Greek word "iatros," meaning physician), the term "comiogenesis" (meaning "care or attendance") might be more appropriate as it implies an organization or system-based standpoint, like in cases of nosocomial infections.
　　There are 2 fundamentally different ways of dealing with medical errors. The first is quality assurance in which individuals performing the error are identified and reprimanded. The second is quality improvement in which the best practice and constant improvement are promoted on a system level. Quality assurance blames the individual and may lead to "error-covering" behavior. In contrast, by focusing on the system, quality improvement promotes error unveiling and perfection. System failures have been described by Leape and coworkers.[4] They analyzed all admissions to 11 medical and surgical units in 2 tertiary care hospitals over a 6-month period and found that 7 systems failures accounted for 78% of the errors. It was stated that all these errors could have been improved by better information systems.
　　There are many studies suggesting that a "closed" ICU system (discussed in detail below) significantly decreases medical errors and even mortality.[5,6] Pharmacists' participation in ICU rounds is another simple measure with a significant impact: Leape and coworkers[7] have reported a decrease of 66% in adverse drug events when the pharmacist is present in rounds as a full member of the ICU team. When the pharmacist was present, 99% of his recommendations were accepted by physicians.
　　Dr. Chalfin concluded that in order to reduce the amount and the seriousness of errors in the hospital, there should be active surveillance methods, increase in applications of information technology, better education and outcomes research, and the application of quality improvement. It is important to move to a system where the error is recognized and admitted, not covered. An efficient system is the one promoting evidence-based medicine and improvement rather than sanctions.