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Intensive Care Medicine
Published in: Intensive Care Medicine 10/2006

01-10-2006 | Original

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study

Authors: Andreas Valentin, Maurizia Capuzzo, Bertrand Guidet, Rui P. Moreno, Lorenz Dolanski, Peter Bauer, Philipp G. H. Metnitz

Published in: Intensive Care Medicine | Issue 10/2006

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Abstract

Objective

To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs).

Design

An observational, 24-h cross-sectional study of incidents in five representative categories.

Setting

205 ICUs worldwide

Measurements

Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed.

Results

In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7–42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00–1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18–2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04–1.08).

Conclusions

Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.
Appendix
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Metadata
Title
Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study
Authors
Andreas Valentin
Maurizia Capuzzo
Bertrand Guidet
Rui P. Moreno
Lorenz Dolanski
Peter Bauer
Philipp G. H. Metnitz
Publication date
01-10-2006
Publisher
Springer-Verlag
Published in
Intensive Care Medicine / Issue 10/2006
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-006-0290-7

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