Error Producing Conditions in the Intensive Care Unit

Up to 98,000 patients die because of human error in U.S. hospitals each year. Among the areas where errors occur frequently is the intensive care unit (ICU). Despite the impact of these errors, little research has identified the human factors that contribute to errors in the ICU. The current study uses the error-producing conditions (EPC) approach to help identify device-related factors that contribute to error. One result of the present study was the identification of the extent to which individual conditions contribute to the prevalence of error. In addition, we identified the contribution of certain devices to the prevalence of error. More importantly, the most critical devices for patient care were also identified as the devices that were rated highest in EPC prevalence. Developing medical devices designed to reduce the device-related potential for patient harm should be a primary goal in patient safety. Introduction Up to 98,000 patients die because of human error in U.S. hospitals each year. Critical care is one of the areas in which human errors occur most frequently. In their seminal paper, Donchin and colleagues estimated that the error rate was 1.7 per patient per day in the intensive care unit (ICU). A study 2 years later found that 45.8 percent of ICU admissions (480 of 1,047 ICU admissions) were associated with an adverse event (AE). More recently, an investigation of the incidence and nature of AEs and medical errors in a medical ICU and a coronary care unit (CCU) collected data during nine 3-week periods. A total of 120 AEs were found in 79 patients, for an AE rate of 20.2 percent. The researchers found that 66 of the 120 AEs (55 percent) were nonpreventable, while 54 of the AEs (45 percent) were preventable. An Australian study suggested that nearly 17 percent of all hospital admissions resulted in an AE, with half of these being preventable. The same study estimated that in Australia, 8 percent of all hospital bed days were a result of AEs. In addition to the costs associated with a longer stay and other potential costs for the hospital, there were also the issues of disability payments and the associated high personal costs for the patients and staff involved in these cases. More recently, due to a change in Medicare in the United States, the costs associated with AEs will be redistributed. Previously, the followup costs for treatment of “serious preventable events” were covered by insurance payments. However, as announced in September 2007, Medicare will no longer cover the followup costs of AEs.