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Volumn 71, Issue 9, 2016, Pages 1013-1023

A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Author keywords

complications; critical care; critical incidents; patient safety

Indexed keywords

HEPARIN; INSULIN; POTASSIUM;

EID: 84982131417     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/anae.13547     Document Type: Article
Times cited : (15)

References (30)
  • 2
    • 84982104536 scopus 로고    scopus 로고
    • (accessed 03/12/2015)
    • National Patient Safety Agency. What is a Patient Safety Incident? 2001. www.npsa.nhs.uk/nrls/reporting/what-is-a-patient-safety-incident/ (accessed 03/12/2015).
    • (2001) What is a Patient Safety Incident?
  • 3
    • 79954556594 scopus 로고    scopus 로고
    • 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
    • Cook TM, Woodall N, Harper J, Benger J, Fourth National Audit Project. 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.
    • (2011) British Journal of Anaesthesia , vol.106 , pp. 632-642
    • Cook, T.M.1    Woodall, N.2    Harper, J.3    Benger, J.4    Fourth National, A.P.5
  • 4
    • 58449135992 scopus 로고    scopus 로고
    • Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists
    • Cook TM, Counsell D, Wildsmith JA, Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 2009; 102: 179–90.
    • (2009) British Journal of Anaesthesia , vol.102 , pp. 179-190
    • Cook, T.M.1    Counsell, D.2    Wildsmith, J.A.3
  • 5
    • 17044393986 scopus 로고    scopus 로고
    • Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000-2002, the Confidential Enquiries into Maternal Deaths in the United Kingdom – Chapter 9: Anaesthesia
    • Cooper GM, McClure JH. Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000-2002, the Confidential Enquiries into Maternal Deaths in the United Kingdom – Chapter 9: Anaesthesia. British Journal of Anaesthesia 2005; 94: 417–423.
    • (2005) British Journal of Anaesthesia , vol.94 , pp. 417-423
    • Cooper, G.M.1    McClure, J.H.2
  • 6
    • 84943339485 scopus 로고    scopus 로고
    • Litigation associated with intensive care unit treatment in England: an analysis of NHSLA data 1995-2012
    • Pascall E, Trehane SJ, Georgiou A, Cook TM. Litigation associated with intensive care unit treatment in England: an analysis of NHSLA data 1995-2012. British Journal of Anaesthesia 2015; 115: 601–607.
    • (2015) British Journal of Anaesthesia , vol.115 , pp. 601-607
    • Pascall, E.1    Trehane, S.J.2    Georgiou, A.3    Cook, T.M.4
  • 7
    • 0025270124 scopus 로고
    • Adverse respiratory events in anaesthesia: a closed claims analysis
    • Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anaesthesia: a closed claims analysis. Anesthesiology 1990; 72: 828–833.
    • (1990) Anesthesiology , vol.72 , pp. 828-833
    • Caplan, R.A.1    Posner, K.L.2    Ward, R.J.3    Cheney, F.W.4
  • 8
    • 84982101968 scopus 로고    scopus 로고
    • (accessed 03/12/2015)
    • The NHS Health Research Authority. Do I need NHS REC approval? 2015. www.hra-decisiontools.org.uk/ethics/ (accessed 03/12/2015).
    • (2015) Do I need NHS REC approval?
  • 11
    • 84862167998 scopus 로고    scopus 로고
    • Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010
    • Thomas AN, Taylor RJ. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Anaesthesia 2012; 67: 706–13.
    • (2012) Anaesthesia , vol.67 , pp. 706-713
    • Thomas, A.N.1    Taylor, R.J.2
  • 12
    • 84902372671 scopus 로고    scopus 로고
    • An analysis of patient safety incidents associated with medications reported from critical care units in the North-West of England between 2009 and 2012
    • Thomas AN, Taylor RJ. An analysis of patient safety incidents associated with medications reported from critical care units in the North-West of England between 2009 and 2012. Anaesthesia 2014; 69: 735–45.
    • (2014) Anaesthesia , vol.69 , pp. 735-745
    • Thomas, A.N.1    Taylor, R.J.2
  • 13
    • 84904971659 scopus 로고    scopus 로고
    • Changes in the rates of reported pressure ulcers in response to a regional critical care quality improvement project
    • Thomas AN, Taylor RJ, Berry A. Changes in the rates of reported pressure ulcers in response to a regional critical care quality improvement project. Journal of the Intensive Care Society 2014; 15: 216–21.
    • (2014) Journal of the Intensive Care Society , vol.15 , pp. 216-221
    • Thomas, A.N.1    Taylor, R.J.2    Berry, A.3
  • 14
    • 84964884502 scopus 로고    scopus 로고
    • Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014
    • Thomas AN, MacDonald JJ. Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014. Journal of the Intensive Care Society 2016; 17: 129–35.
    • (2016) Journal of the Intensive Care Society , vol.17 , pp. 129-135
    • Thomas, A.N.1    MacDonald, J.J.2
  • 18
    • 84915809367 scopus 로고    scopus 로고
    • Cambridge, MA, Institute for Healthcare Improvement, (accessed 03/12/2015)
    • Institute for Healthcare Improvement. How-to guide: prevent harm from high-alert medications. Cambridge, MA: Institute for Healthcare Improvement, 2012. www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedications.aspx (accessed 03/12/2015).
    • (2012) How-to guide: prevent harm from high-alert medications
  • 20
    • 84885960293 scopus 로고    scopus 로고
    • Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis
    • Gupta KJ, Cook TM. Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis. Anaesthesia 2013; 68: 1179–87.
    • (2013) Anaesthesia , vol.68 , pp. 1179-1187
    • Gupta, K.J.1    Cook, T.M.2
  • 24
    • 84862158605 scopus 로고    scopus 로고
    • (accessed 01/12/2015)
    • National tracheostomy safety project. Resources: Airway Algorithms, 2007. www.tracheostomy.org.uk/Tracheostomy/New%20Blue%20Trachy%20Webpages/New%20Resources.htm (accessed 01/12/2015).
    • (2007) Resources: Airway Algorithms
  • 25
    • 4143134187 scopus 로고    scopus 로고
    • Incidents relating to the intra-hospital transfer of critically ill patients – an analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care
    • Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients – an analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Medicine 2004; 30: 1579–85.
    • (2004) Intensive Care Medicine , vol.30 , pp. 1579-1585
    • Beckmann, U.1    Gillies, D.M.2    Berenholtz, S.M.3    Wu, A.W.4    Pronovost, P.5
  • 26
    • 33645209337 scopus 로고    scopus 로고
    • Quality of interhospital transport of critically ill patients: a prospective audit
    • Ligtenberg JJM, Arnold LG, Stienstra Y, et al. Quality of interhospital transport of critically ill patients: a prospective audit. Critical Care 2005; 9: R446–51.
    • (2005) Critical Care , vol.9 , pp. R446-R451
    • Ligtenberg, J.J.M.1    Arnold, L.G.2    Stienstra, Y.3
  • 28
    • 84982123237 scopus 로고    scopus 로고
    • (accessed 03/12/2015)
    • Intensive Care National Audit and Research Centre. About the CMP, 2015. www.icnarc.org/Our-Audit/Audits/Cmp/About (accessed 03/12/2015).
    • (2015) About the CMP
  • 29
  • 30
    • 1642533561 scopus 로고    scopus 로고
    • Guidelines for the inter- and intrahospital transport of critically ill patients
    • Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM, American College of Critical Care Medicine. Guidelines for the inter- and intrahospital transport of critically ill patients. Critical Care Medicine 2004; 32: 256–62.
    • (2004) Critical Care Medicine , vol.32 , pp. 256-262
    • Warren, J.1    Fromm, R.E.2    Orr, R.A.3    Rotello, L.C.4    Horst, H.M.5


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.