Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010

Anaesthesia

Volumn 67, Issue 7, 2012, Pages 706-713

  Thomas, A N ^a   Taylor, R J ^a  

^a SALFORD ROYAL NHS FOUNDATION TRUST   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DECUBITUS; FLUSHING; HARM REDUCTION; HOSPITAL; HUMAN; INCIDENT REPORT; INTENSIVE CARE UNIT; MEDICAL AUDIT; MEDICAL ETHICS; PATIENT CARE; PATIENT SAFETY; PRACTICE GUIDELINE; UNITED KINGDOM;

CRITICAL CARE; ENGLAND; HUMANS; INTENSIVE CARE UNITS; MEDICAL AUDIT; MEDICAL ERRORS; PATIENT SAFETY; PRESSURE ULCER; RETROSPECTIVE STUDIES; SAFETY MANAGEMENT;

EID: 84862167998     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/j.1365-2044.2012.07141.x     Document Type: Article

References (28)

1. Wright D, Mackenzie SJ, Buchan I. Critical incidents in the intensive therapy unit. Lancet 1991; 338: 678.
2. National patient agency. Report a patient safety incident. http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/(accessed 14 ? 03 ? 2012).
3. Shaw R, Drever F, Hughes H, Osborn SS, Williams SK. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care 2005; 14: 279-83. (Pubitemid 41133183)
4. Williams SK, Osborn SS. The development of the national reporting and learning system in England and Wales, 2001-2005. Medical Journal of Australia 2006; 184: (Suppl. 10) S65-8. (Pubitemid 43732928)
5. Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2009; 64: 358-65.
6. National patient safety agency. Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA ? 2011 ? PSA002 10. 2011. http://www.nrls.npsa.nhs.uk/resources/?EntryIds5 = 129640 (accessed 10/ 01/2012).
7. National patient safety agency. Problems with infusions and sampling from arterial lines Rapid response 2008/RRR006. 2008. http://www.nrls.npsa.nhs.uk/ resources/?EntryId45=59891 (accessed 10 ? 01 ? 2012).
8. National Research Ethics Service. Defining Research NRES guidance to help you decide if your project requires review by a Research Ethics Committee. 2009. http://www.nres.npsa.nhs.uk/applications/is-your-project-research/ (accessed 10/01/2012).
9. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel. 2009. http://www.epuap.org/guidelines/Final-Quick-Treatment.pdf. (accessed 10/01/2012).
10. Intensive Care Society. Incident reporting. 2011. http://www.ics.ac.uk/ intensive-care-professional/incident-reporting (accessed 10/01/2012).
11. National tracheostomy safety project. Resources: airway algorithms. 2007. http://www.tracheostomy.org.uk/Tracheostomy/New%20Blue%20Trachy%20Webpages/ New%20Resources.htm (accessed 10/01/2012).
12. Snijders C, van Lingen RA, Klip H, Fetter WPF, van der Schaaf TW, Molendijk HA. Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Archives of Disease in Childhood-Fetal and Neonatal Edition 2009; 94: F210-5.
13. Cook TM, Woodall N, Harper J, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia 2011; 106: 632-42.
14. Association of Anaesthetists of Great Britain and Ireland. Safety statement: the use of capnography outside the operating theatre. 2011. http://www.aagbi.org/sites/default/files/Capnographyaagbi090711AJH%5B1%5D-0.pdf (accessed 10/01/2012).
15. Royal College of Anaesthetists and Difficult Airway Society: Press release: Major complications of airway management in the UK. 2011. http://www.rcoa.ac.uk/docs/NAP4-pr.pdf (accessed 10/01/2012).
16. Intensive Care Society.Guidelines for the use of capnography in critical care. 2011. http://www.ics.ac.uk/intensive-care-professional/standards-safety- and-quality#Clinical%20Practice (accessed 10 ? 01 ? 2012).
17. Silas R, Tibballs J. Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit. Quality and Safety in Health Care 2010; 19: 568-71.
18. Thomas AN, Boxall EM, Sabbagh G, et al. An audit and review of hypoglycaemia in critical care. Journal of the Intensive Care Society 2006; 7: 19-21.
19. National Institute for Clinical Excellence. Pressure ulcers; the management of pressure ulcers in primary and secondary care. NICE clinical guideline 29. 2005. http://www.nice.org.uk/nicemedia/live/10972/57623/57623.pdf (accessed 10/01/2012).
20. Manzano F, Navarro MJ, Roldan D, et al. Pressure ulcer incidence and risk factors in ventilated intensive care patients. Journal of Critical Care 2010; 25: 469-76.
21. Bours G, De Laat EH, Halfens RJG, Lubbers M. Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units - results of a cross-sectional survey. Intensive Care Medicine 2001; 27: 1599-605. (Pubitemid 33027956)
22. Bennett G, Dealey C, Posnett J, The cost of pressure ulcers in the UK. Age and Ageing 2004; 33: 230-5. (Pubitemid 38635038)
23. Gorecki C, Closs SJ, Nixon J, Briggs H. Patient-reported pressure ulcer pain: a mixed-methods systematic review. Journal of Pain and Symptom Management 2011; 42: 443-59.
24. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. Journal of Advanced Nursing 2006; 56: 345-53. (Pubitemid 44583459)
25. Citak M, Backhaus M, Tilkorn DJ, et al. Necrotizing fasciitis in patients with spinal cord injury: an analysis of 25 patients. Spine 2011; 36: E1225-9.
26. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. Journal of the American Medical Association 2006; 296: 974-84. (Pubitemid 44285374)
27. de Laat EH, Pickkers P, Schoonhoven L, Verbeek AL, Feuth T, van Achterberg T. Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. Critical Care Medicine 2007; 35: 815-20. (Pubitemid 46407796)
28. Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate pressure ulcers in critical care. Journal of Nursing Care Quality 2011; 26: 216-25.