Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: A root cause analysis of unplanned ICU admissions

PLoS ONE

Volumn 11, Issue 8, 2016, Pages

  Van Galen, Louise S ^a   Struik, Patricia W ^a   Driesen, Babiche E J M ^a   Merten, Hanneke ^b   Ludikhuize, Jeroen ^c   Van Der Spoel, Johannes I ^a   Kramer, Mark H H ^a   Nanayakkara, Prabath W B ^a  

^a VU UNIVERSITY MEDICAL CENTER   (Netherlands)

^b VU UNIVERSITY MEDICAL CENTER   (Netherlands)

^c ACADEMIC MEDICAL CENTER   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; AGED; ARTICLE; CAUSAL ATTRIBUTION; CLINICAL ARTICLE; DETERIORATION; FEMALE; HEALTH CARE PLANNING; HOSPITAL ADMISSION; HUMAN; INTENSIVE CARE UNIT; MALE; MEDICAL ERROR; MEDICAL RECORD REVIEW; OBSERVATIONAL STUDY; PATIENT CARE; PATIENT MONITORING; VITAL SIGN; WARD; CRITICAL ILLNESS; DELAYED DIAGNOSIS; HOSPITALIZATION; MIDDLE AGED; PHYSIOLOGIC MONITORING; PSYCHOLOGY; RETROSPECTIVE STUDY; ROOT CAUSE ANALYSIS; STATISTICS AND NUMERICAL DATA; VERY ELDERLY;

ADULT; AGED; AGED, 80 AND OVER; CRITICAL ILLNESS; DELAYED DIAGNOSIS; FEMALE; HOSPITALIZATION; HUMANS; INTENSIVE CARE UNITS; MALE; MEDICAL ERRORS; MIDDLE AGED; MONITORING, PHYSIOLOGIC; RETROSPECTIVE STUDIES; ROOT CAUSE ANALYSIS;

EID: 84984617590     PISSN: None     EISSN: 19326203     Source Type: Journal    
DOI: 10.1371/journal.pone.0161393     Document Type: Article

References (36)

1. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008; 17(3):216-23. doi: 10.1136/qshc.2007.023622 PMID: 18519629
2. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995; 163(9):458-71. PMID: 7476634
3. Vlayen A, Verelst S, Bekkering GE, Schrooten W, Hellings J, Claes N. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract. 2012; 18(2):485-97. doi: 10.1111/j.1365-2753.2010.01612.x PMID: 21210898
4. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324(6):377-84. PMID: 1824793
5. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009; 18(4):297-302. doi: 10.1136/qshc.2007.025924 PMID: 19651935
6. Arts D, de Keizer N, Scheffer GJ, de Jonge E. Quality of data collected for severity of illness scores in the Dutch National Intensive Care Evaluation (NICE) registry. Intensive Care Med. 2002; 28(5):656-9. PMID: 12029418
7. Ridley S, Jackson R, Findlay J, Wallace P. Long term survival after intensive care. BMJ. 1990; 301(6761):1127-30. PMID: 2252923
8. Alam N, Vegting IL, Houben E, van Berkel B, Vaughan L, Kramer MH, et al. Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department. Resuscitation. 2015; 90:111-5. doi: 10.1016/j.resuscitation.2015.02.011 PMID: 25748878
9. Hillman K, Parr M, Flabouris A, Bishop G, Stewart A. Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation. 2001; 48(2):105-10. PMID: 11426471
10. Moon A, Cosgrove JF, Lea D, Fairs A, Cressey DM. An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation. 2011; 82(2):150-4. doi: 10.1016/j.resuscitation.2010.09.480 PMID: 21056524
11. Subbe CP, Gao H, Harrison DA. Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med. 2007; 33(4):619-24. PMID: 17235508
12. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007(3: ):CD005529. PMID: 17636805
13. Quinn TD, Gabriel RA, Dutton RP, Urman RD. Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit. J Intensive Care Med. 2015.
14. Mercier E, Giraudeau B, Ginies G, Perrotin D, Dequin PF. Iatrogenic events contributing to ICU admission: a prospective study. Intensive Care Med. 2010; 36(6):1033-7. doi: 10.1007/s00134-010-1793-9 PMID: 20217046
15. Darchy B, Le Miere E, Figueredo B, Bavoux E, Domart Y. Iatrogenic diseases as a reason for admission to the intensive care unit: incidence, causes, and consequences. Arch Intern Med. 1999; 159(1):71-8. PMID: 9892333
16. Fluitman KS, van Galen LS, Merten H, Rombach SM, Brabrand M, Cooksley T, et al. Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link. Eur J Intern Med. 2016.
17. van der Schaaf TW HM. PRISM-Medical. A Brief Description. Eindhoven University of Technology, Faculty of Technology Management, Patient Safety Systems: Eindhoven,. 2005.
18. van Vuuren W SC, van der Schaaf TW. The Development of an Incident Analysis Tool For the Medical Field. Eindhoven University of Technology: Eindhoven. 1997.
19. van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010; 97(11):1730-40. doi: 10.1002/bjs.7201 PMID: 20661930
20. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985; 13(10):818-29. PMID: 3928249
21. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993; 270(24):2957-63. PMID: 8254858
22. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006; 34(5):1297-310. PMID: 16540951
23. Rasmussen J. Skills, rules and knowledge: signals, signs and symbols and other distinctions in human performance models. IEEE Trans Systems Man Cybernetics. 1983; 13:257-66.
24. Reason JT. Human Error. Cambridge University Press. 1990.
25. Reason JT. Managing the Risk of Organisational Accidents. Asgate Aldershot. 1997.
26. Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care. 2009; 21(1):18-26. doi: 10.1093/intqhc/mzn057 PMID: 19147597
27. Sherman H, Castro G, Fletcher M, Hatlie M, Hibbert P, Jakob R, et al. Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Health Care. 2009; 21(1):2-8. doi: 10.1093/intqhc/mzn054 PMID: 19147595
28. Runciman WB, Williamson JA, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care. 2006; 15 Suppl 1:i82-90. PMID: 17142615
29. Storm-Versloot MN, Verweij L, Lucas C, Ludikhuize J, Goslings JC, Legemate DA, et al. Clinical relevance of routinely measured vital signs in hospitalized patients: a systematic review. J Nurs Scholarsh. 2014; 46(1):39-49. doi: 10.1111/jnu.12048 PMID: 24124656
30. Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med. 2011; 6(2):68-72. doi: 10.1002/jhm.812 PMID: 21290577
31. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond. 1999; 33(3):255-9. PMID: 10402575
32. Frost SA, Alexandrou E, Bogdanovski T, Salamonson Y, Parr MJ, Hillman KM. Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk. Resuscitation. 2009; 80(2):224-30. doi: 10.1016/j.resuscitation.2008.10.030 PMID: 19084319
33. Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. J Hosp Med. 2007; 2(6):422-32. PMID: 18081187
34. Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008; 300(21):2506-13. doi: 10.1001/jama.2008.715 PMID: 19050194
35. Ludikhuize J, Borgert M, Binnekade J, Subbe C, Dongelmans D, Goossens A. Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: a quasi-experimental study. Resuscitation. 2014; 85(5):676-82. doi: 10.1016/j.resuscitation.2014.02.009 PMID: 24561029
36. van Galen LS, Dijkstra CC, Ludikhuize J, Kramer MHH, Nanayakkara PWB. A protocolised once a day modified early warning score (MEWS) measurement is an appropriate screening tool for major adverse events in a general hospital population. Running title: "A MEWS in the morning, a very good warning". PLOS ONE Accepted 27-6-2016. 2016.