Safety and quality in intensive care medicine;Seguridad y Calidad en Medicina Intensiva

Medicina Intensiva

Volumn 33, Issue 7, 2009, Pages 346-352

  Romero, C M ^a  

^a HOSPITAL CLÍNICO UNIVERSIDAD DE CHILE   (Chile)

Author keywords

Adverse effects; Bundle; ICU; Medical errors; Quality control; Safety

Indexed keywords

ANTIBIOTIC AGENT; VASOACTIVE AGENT;

ARTICLE; ARTIFICIAL VENTILATION; BACTERIAL INFECTION; BLOOD CULTURE; CRITICALLY ILL PATIENT; HARM REDUCTION; HEALTH CARE DELIVERY; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HUMAN; HYPOTENSION; INTENSIVE CARE; INTENSIVE CARE UNIT; MEDICAL ERROR; MEDICAL INSTRUMENTATION; MEDICATION ERROR; PATIENT CARE; PATIENT SAFETY; SEPTIC SHOCK; TEAMWORK; VENTILATOR ASSOCIATED PNEUMONIA;

HUMANS; INTENSIVE CARE; RESPIRATION, ARTIFICIAL; SAFETY;

EID: 70349414277     PISSN: 02105691     EISSN: 15786749     Source Type: Journal    
DOI: 10.1016/j.medin.2009.03.001     Document Type: Article

References (100)

1. st century (2001), National Academy Press, Washington, DC
2. Berenholtz S.M., Pustavoitau A., Schwartz S.J., and Pronovost P.J. How safe is my intensive care unit? Methods for monitoring and measurement. Curr Opin Crit Care 13 (2007) 703-708
3. Sexton J., Thomas E.J., and Helmreich R.L. Error, stress and teamwork in medicine and aviation: Cross sectional surveys. BMJ 320 (2000) 745-749
4. Pronovost P.J., Angus D.C., Dorman T., Robinson K.A., Dremsizov T.T., and Young T.L. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 288 (2002) 2151-2162
5. Pronovost P.J., Holzmueller C.G., Needham D.M., Sexton J.B., Miller M., Berenholtz S., et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med 34 (2006) 1988-1995
6. Berenholtz S.M., Dorman T., Ngo K., and Pronovost P.J. Qualitative review of intensive care unit quality indicators. J Crit Care 17 (2002) 1-15
7. De Vos M., Graafmans W., Keesman E., Westert G., and Van der Voort P. Quality measurement at intensive care units: Which indicators should we use?. J Crit Care 22 (2007) 267-274
8. Domínguez L., Enríquez P., Álvarez P., De Frutos M., Sagredo V., Domínguez A., et al. Mortalidad y estancia hospitalaria ajustada por gravedad como indicadores de efectividad y eficiencia de la atención de pacientes en unidades de cuidados intensivos. Med Intensiva 32 (2008) 8-14
9. Martín M.C., Cabré L.I., Ruiz J., Blanch L.I., Blanco J., Castillo F., et al. Indicadores de calidad en el enfermo crítico. Med Intensiva 32 (2008) 23-32
10. Pronovost P.J., Nolan T., Zeger S., Miller M., and Rubin H. How can clinicians measure safety and quality in acute care?. Lancet 363 (2004) 1061-1067
11. Pronovost P.J., Weast B., Holzmueller C.G., Rosenstein B.J., Kidwell R.P., Haller K.B., et al. Evaluation of the culture of safety: Survey of clinicians and managers in an academic medical center. Qual Saf Health Care 12 (2003) 405-410
12. Berenholtz S.M., and Pronovost P.J. Monitoring patient safety. Crit Care Clin 23 (2007) 659-673
13. Pronovost P.J., Berenholtz S.M., Goeschel C., Thom I., Watson S.R., Holzmueller C.G., et al. Improving patient safety in intensive care units in Michigan. J Crit Care 23 (2008) 207-221
14. Sexton J.B., Helmreich1 R.L., Neilands T.B., Rowan K., Vella K., Boyden J., et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 6 (2006) 44-53
15. Pronovost P.J., Weast B., Rosenstein B., Sexton J.B., Holzmueller C.G., Paine L., et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 1 (2005) 33-40
16. Curtis J.R., Cook D.J., Wall R.J., Angus D.C., Bion J., Kacmarek R., et al. Intensive care unit quality improvement: A "how-to" guide for the interdisciplinary team. Crit Care Med 34 (2006) 211-218
17. McCauley K., and Irwin R.S. Changing the work environment in ICUs to achieve patient-focused care: The time has come. Chest 130 (2006) 1571-1578
18. Hayward R.A., and Hofer T.P. Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. JAMA 286 (2001) 415-420
19. Bion J.F., and Heffner J. Challenges in the care of the acutely ill. Lancet 363 (2004) 970-977
20. Pawlson L.G., and O'Kane M.E. Malpractice prevention, patient safety, and quality of care: A critical linkage. Am J Manag Care 10 (2004) 281-284
21. Donchin Y., Gopher D., Olin M., Badihi Y., Biesky M., Sprung C.L., et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 23 (1995) 294-300
22. Wu A.W., Pronovost P., and Morlock L. ICU incident reporting systems. J Crit Care 17 (2002) 86-94
23. Roca J., Pérez J.M., Colmenero M., Muñoz H., Alarcón L., and Vázquez G. Competencias profesionales para la atención al paciente crítico. Más allá de las especialidades. Med Intensiva 31 (2007) 473-484
24. Andrews L.B., Stocking C., Krizek T., Gottlieb L., Krizek C., Vargish T., et al. An alternative strategy for studying adverse events in medical care. Lancet 349 (1997) 309-313
25. Osmon S., Harris C.B., Dunagan W.C., Prentice D., Fraser V.J., and Kollef M.H. Reporting of medical errors: An intensive care unit experience. Crit Care Med 32 (2004) 727-733
26. Boyle D., O'Connell D., Platt F.W., and Albert R.K. Disclosing errors and adverse events in the intensive care unit. Crit Care Med 34 (2006) 1532-1537
27. Kaushal R., Bates D.W., Franz C., Soukup J.R., and Rothschild J.M. Costs of adverse events in intensive care units. Crit Care Med 35 (2007) 2479-2483
28. Pronovost P.J., Berenholtz S., Dorman T., Lipsett P.A., Simmonds T., and Haraden C. Improving communication in the ICU using daily goals. J Crit Care 18 (2003) 71-75
29. Hales B.M., and Pronovost P.J. The checklist-a tool for error management and performance improvement. J Crit Care 21 (2006) 231-235
30. Leape L.L. Reporting of adverse events. N Engl J Med 347 (2002) 1633-1638
31. Vincent C. Understanding and responding to adverse events. N Engl J Med 348 (2003) 1051-1056
32. Valentin A., Capuzzo M., Guidet B., Moreno R.P., Dolanski L., Bauer P., et al. Patient safety in intensive care: Results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med 32 (2006) 1591-1598
33. Wu A.W., Lipshutz A., and Pronovost P.J. Effectiveness and efficiency of root cause analysis in medicine. JAMA 299 (2008) 685-687
34. Gutiérrez Cía I., Obón Azuara B., and Aibar Remón C. Análisis de los «casi errores». Un nuevo enfoque en el estudio de los acontecimientos adversos. Med Intensiva 32 (2008) 143-146
35. Rothschild J.M., Landrigan C.P., Cronin J.W., Kaushal R., Lockley S.W., Burdick E., et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 33 (2005) 1694-1700
36. Miller M.R., Robinson K.A., Lubomski L.H., Rinke M.L., and Pronovost P.J. Medication errors in paediatric care: A systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care 16 (2007) 116-126
37. Van den Bemt P.M., Fijn R., Van der Voort P.H., Gossen A.A., Egberts T.C., and Brouwers J.R. Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 30 (2002) 846-850
38. Moyen E., Camiré E., and Stelfox H.T. Clinical review: Medication errors in critical care. Crit Care 12 (2008) 208
39. Bertsche T., Mayer I., Stahl R., Hoppe-Tichy T., Encke J., and Haefeli W.E. Prevention of intravenous drug incompatibilities in an intensive care unit. Am J Health Syst Pharm 65 (2008) 1834-1840
40. Husch M., Sullivan C., Rooney D., Barnard C., Fotis M., Clarke J., et al. Insights from the sharp end of intravenous medication errors: Implications for infusion pump technology. Qual Saf Health Care 14 (2005) 80-86
41. Adachi W., and Lodolce A.E. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm 62 (2005) 917-920
42. Siv-Lee L., and Morgan L. Implementation of wireless "intelligent" pump IV infusion technology in a not-for-profit academic hospital setting. Hosp Pharm 42 (2007) 832-840
43. Eskew J.A., Jacobi J., Buss W.E., Warhurst H., and DeBord C. Using innovative technologies to new safety standards for the infusion of intravenous medications. Hosp Pharm 37 (2002) 1179-1189
44. Rothschild J.M., Keohane C.A., Cook E.F., Orav E.J., Burdick E., Thompson S., et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 33 (2005) 533-540
45. Fanikos J., Fiumara K., Baroletti S., Luppi C., Saniuk C., Mehta A., et al. Impact of smart infusion technology on administration of anticoagulants (unfractionated heparin, argatroban, lepirudin, and bivalirudin). Am J Cardiol 99 (2007) 1002-1005
46. Hess J., and Whiting S. Making an intelligent smart pump purchase. Mater Manag Health Care 16 (2007) 38-41
47. Murdoch L.J., and Cameron V.L. Smart infusion technology: A minimum safety standard for intensive care?. Br J Nurs 17 (2008) 630-636
48. Arancibia F., Fica A., Herbe B., Ruiz M., and Yunge M. Consenso chileno sobre neumonía asociada a ventilación mecánica. Diagnóstico de neumonía asociada a ventilación mecánica. Rev Chil Infectol 18 (2001) 41-57
49. Brito V., and Niederman M.S. Standardized care for nosocomial pneumonia is a valuable tool to improve patient outcomes: How do we get intensivists to listen?. Crit Care Med 37 (2009) 350-352
50. Warren D.K., Shukla S.J., Olsen M.A., Kollef M.H., Hollenbeak C.S., Cox M.J., et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 31 (2003) 1312-1317
51. Klevens R.M., Edwards J.R., Richards Jr. C.L., Horan T.C., Gaynes R.P., Pollock D.A., et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 122 (2007) 160-166
52. Safdar N., Dezfulian C., Collard H., and Sanjay S. Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Crit Care Med 33 (2005) 2184-2193
53. Kollef M.H. The prevention of ventilator-associated pneumonia. N Engl J Med 340 (1999) 627-634
54. Hernández G., Dalmazzo R., De la Cerda G., Saavedra C., and Calvo M. Consenso chileno sobre neumonía asociada a ventilación mecánica. Prevención de la neumonía asociada a la ventilación mecánica. Rev Chil Infectol 18 (2001) 66-76
55. Niederman M.S., Craven D.E., Bonten M.J., Chastre J., Craig W.A., Fagon J.Y., et al. Official statement of the American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171 (2005) 388-416
56. Brook A.D., Ahrens T.S., Schaiff R., Prentice D., Sherman G., Shannon W., et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 27 (1999) 2609-2615
57. Kress J.P., Pohlman A.S., O'Connor M.F., and Hall J.B. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342 (2000) 1471-1477
58. De Jonghe B., Bastuji-Garin S., Fangio P., Lacherade J.C., Jabot J., Appéré-De-Vecchi C., et al. Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med 33 (2005) 120-127
59. Romero C., Bruhn A., and De la Fuente R. Sedación y analgesia en sepsis. Rev Chil Med Intensiva 21 (2006) 236-246
60. Tobar E., Lanas A., Pino S., Aspée P., Rivas S., Prat D., et al. Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica. Rev Med Chile 136 (2008) 711-718
61. Pandharipande P.P., Pun B.T., Herr D.L., Maze M., Girard T.D., Miller R.R., et al. Effect of sedation with dexmedetomidine vs. lorazepam on acute brain dysfunction in mechanically ventilated patients: The MENDS randomized controlled trial. JAMA 298 (2007) 2644-2653
62. Riker R., Shehabi Y., Bokesch P.M., Ceraso D., Wisemandle W., Koura F., et al. Dexmedetomidine vs. midazolam for sedation of critically ill patients. A randomized trial. JAMA 301 (2009) 489-499
63. Girard T.D., Pandharipande P.P., and Ely E.W. Delirium in the intensive care unit. Crit Care 12 (2008) S3-S11
64. Tobin M.J. Remembrance of weaning past: The seminal papers. Intensive Care Med 32 (2006) 1485-1493
65. Tobin M.J., and Jubran A. Meta-analysis under the spotlight: Focused on a meta-analysis of ventilator weaning. Crit Care Med 36 (2008) 1-7
66. Brochard L., Rauss A., Benito S., Conti G., Mancebo J., Rekik N., et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150 (1994) 896-903
67. Ely E.W., Baker A.M., Dunagan D.P., Burke H.L., Smith A.C., Kelly P.T., et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335 (1996) 1864-1869
68. Esteban A., Alía I., Gordo F., Fernández R., Solsona J.F., Vallverdú I., et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 156 (1997) 459-465
69. Esteban A., Alía I., Tobin M.J., Gil A., Gordo F., Vallverdú I., et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 159 (1999) 512-518
70. Girard T.D., Kress J.P., Fuchs B.D., Thomason J.W., Schweickert W.D., Pun B.T., et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. Lancet 371 (2008) 126-134
71. Vincent J.L. Evidence-based medicine in the ICU: Important advances and limitations. Chest 126 (2004) 592-600
72. Resar R., Pronovost P., Haraden C., Simmonds T., Rainey T., and Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 31 (2005) 243-248
73. Berriel-Cass D., Adkins F.W., Jones P., and Fakih M.G. Eliminating nosocomial infections at ascension health. Jt Comm J Qual Patient Saf 32 (2006) 612-620
74. Youngquist P., Carroll M., Farber M., Macy D., Madrid P., Ronning J., et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 33 (2007) 219-225
75. Tomicic V., Espinoza M., Andresen M., Molina J., Calvo M., Ugarte H., et al. Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno. Rev Med Chil 136 (2008) 959-967
76. Dougnac A., Mercado M., Cornejo R., Cariaga M., Hernández G., Andresen M., et al. Prevalencia de sepsis grave en las unidades de cuidado intensivo. Primer estudio nacional multicéntrico. Rev Med Chil 135 (2007) 620-630
77. Rivers E.P., Nguyen B., Havstad S., Ressler J., Muzzin A., Knoblich B., et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345 (2001) 1368-1377
78. Rivers E.P., and Ahrens T. Improving outcomes for severe sepsis and septic shock: Tools for early identification of at-risk patients and treatment protocol implementation. Crit Care Clin 24 (2008) S1-S47
79. Romero C., Cornejo R., Tobar E., Gálvez R., Llanos O., and Castro J. Reanimación protocolizada del shock séptico. Rev Hosp Clín Univ Chile 19 (2008) 127-141
80. Castro R., Regueira T., Aguirre M.L., Llanos O.P., Bruhn A., Bugedo G., et al. An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock. Minerva Anestesiol 74 (2008) 223-231
81. Levy M.M., Pronovost P.J., Dellinger R.P., Townsend S., Resar R.K., Clemmer T.P., et al. Sepsis change bundles: Converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 32 (2004) S595-S597
82. Dellinger R.P., Levy M.M., Carlet J.M., Bion J., Parker M.M., Jaeschke R., et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36 (2008) 296-327
83. Gao F., Melody T., Daniels D.F., Giles S., and Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: A prospective observational study. Crit Care 9 (2005) 764-770
84. Nguyen H.B., Corbett S.W., Steele R., Banta J., Clark R.T., Hayes S.R., et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 35 (2007) 1105-1112
85. Mermel L.A. Prevention of intravascular catheter-related infections. Ann Intern Med 132 (2000) 391-402
86. Brenner P., Bugedo G., Calleja D., Del Valle G., Fica A., Gómez M.E., et al. Consenso nacional sobre infecciones asociadas a catéteres vasculares centrales. Prevención de infecciones asociadas a catéteres vasculares centrales. Rev Chil Infect 20 (2003) 51-69
87. McGee D.C., and Gould M.K. Preventing complications of central venous catheterization. N Engl J Med 348 (2003) 1123-1133
88. Berenholtz S.M., Pronovost P.J., Lipsett P.A., Hobson D., Earsing K., Farley J.E., et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32 (2004) 2014-2020
89. Labeau S.O., Vandijck D.M., Rello J., Adam S., Rosa A., Wenisch C., et al. Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: Results of a knowledge test among 3405 European intensive care nurses. Crit Care Med 37 (2009) 320-323
90. Ash S.R. Advances in tunneled central venous catheters for dialysis: Design and performance. Semin Dial 21 (2008) 504-515
91. Casey A.L., Mermel L.A., Nightingale P., and Elliott T.S. Antimicrobial central venous catheters in adults: A systematic review and meta-analysis. Lancet Infect Dis 8 (2008) 763-776
92. Timsit J.F., Farkas J.C., Boyer J.M., Martin J.B., Misset B., Renaud B., et al. Central vein catheter-related thrombosis in intensive care patients: Incidence, risks factors, and relationship with catheter-related sepsis. Chest 114 (1998) 207-213
93. Menyhay S.Z., and Maki D.G. Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: The promise of a novel antiseptic-barrier cap. Infect Control Hosp Epidemiol 27 (2006) 23-27
94. Schilling S., Doellman D., Hutchinson N., and Jacobs B.R. The impact of needleless connector device design on central venous catheter occlusion in children: A prospective controlled trial. JPEN J Parenter Enteral Nutr 30 (2006) 85-90
95. Menyhay S.Z., and Maki D.G. Preventing central venous catheter-associated bloodstream infections: Development of an antiseptic barrier cap for needleless connectors. Am J Infect Control 36 (2008) S174.e1-S174.e5
96. Jasinsky L.M., and Wurster J. Occlusion reduction and heparin elimination trial using an antireflux device on peripheral and central venous catheters. J Infus Nurs 32 (2009) 33-39
97. Shapey I.M., Foster M.A., Whitehouse T., Jumaa P., and Bion J.F. Central venous catheter-related bloodstream infections: Improving post-insertion catheter care. J Hosp Infect 71 (2009) 117-122
98. Pronovost P.J., Needham D., Berenholtz S., Sinopoli D., Chu H., Cosgrove S., et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355 (2006) 2725-2732
99. Lisboa T., and Rello J. Prevención de infecciones nosocomiales: estrategias para mejorar la seguridad de los pacientes en la unidad de cuidados intensivos. Med Intensiva 32 (2008) 248-252
100. Gallesio A.O. Improving quality and safety in the ICU: A challenge for the next years. Curr Opin Crit Care 14 (2008) 700-707