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Int J Qual Health Care. 2012 Apr;24(2):105-13. doi: 10.1093/intqhc/mzr083. Epub 2011 Dec 21.

Adverse events in Spanish intensive care units: the SYREC study.

Collaborators (158)

Cánovas Robles J, Perales Pastor R, Sánchez Ortega D, Serrano Calvache JA, De Rojas Román JP, Ramos Carbonero Y, Gutiérrez Fernández MJ, Fernández Álvarez V, Umaran Sarachu MI, Monguillo Martiregui, Fernández Dorado F, Figueras Coloma E, Morillas Pérez J, Portillo Jaurena E, Sánchez Segura JM, Sola Sole N, Zavala Zegarra E, Cirerea A, Vázquez Sánchez A, Abad Peruga V, Robles González A, Borja García MI, Bellot Iglesias JL, Martínez Molina M, Romero Pellerrejo J, Campillo Temiño C, Martínez Hernández J, Alarcón Simarro N, Álvaro Sánchez R, Bernat Adell A, Molina Domínguez E, Ortega Carnicer J, Alcalá López A, Pastor M, Palomeque Rico A, Nicolás Zambudio G, Alonso Ovies A, Balugo Huertas S, Audicana Uriarte J, Sánchez Villamar AM, Álvarez Villuendas A, Garfingou Llenas D, Roca Guiseris J, García R, Fernández del Campo R, Buendía F, Bartual Lobato E, García Verdejo JA, Verduras Ruiz MA, Rodrigo Frontelo R, Pavía Pesquera MC, Pardos Peirós E, Blanco Pérez J, Murado Bouso AM, Gómez Tello V, del Pozo Y, Reyes García A, Toledano Peña J, Ramos Polo J, Suay Ojalvo C, Menéndez de Suso JJ, Segovia Gaitán M, Sáenz Casco L, Andrés Sarriá M, Jiménez Lendínez M, Romero C, Arias Verdú MD, García Santana JL, Arboleda Sánchez JA, Velasco Bueno JM, Solsona Perlasia M, Vilalta Llibre M, García Fernández AM, Morales Adeva L, Galdos Anuncibay P, Arias Castro I, Gómez Ramos MJ, Cevidanes M, Martínez Fresneda M, Banacloche Cano C, Carrillo Alcaraz A, Peñalver F, Iglesias Fraile L, Álvarez Méndez B, Rialp Cervera G, Bestard Socías C, Rodríguez Albarrán F, Ballester Belcos R, Ramos Castro J, Herranz Ayesa MV, Martinez Urionabarrenetxea K, Elizondo Soto A, Gil Cebrián J, Delgado Poullet N, Prieto Valderrey F, Nieto Galeano J, Rovira Angles C, Cerrillo E, Domínguez López S, Malnero López M, Baigorri González F, Jam Gatell R, Lacueva Moya V, Hernández Santamaría F, González Robledo J, Coca Hernández MA, Azkárate Ayerdi B, Marcos A, Rull Rodríguez VE, Morras Pineda B, Gilavert Cuevas MC, Aragonés M, Jurado Castro MT, Bell Ribatallada M, Pérez-Pedrero Sánchez-Belmonte MJ, Pinilla López A, Vázquez Casas JR, Herrero Gómez E, Soto Ibáñez JM, Romero Morán MA, García Galiana E, Fernández Martínez A, Domínguez Quintero LA, Acebes Sancho BE, Domínguez Quintero LA, Palencia García MA, Tizón Varela AI, de Castro Rodríguez P, Manzano Ramírez A, Ruiz de Ofenda E, Marcos Gutiérrez A, Larruscain León MV, Temiño Palomera S, Lasheras Palomero L, Gutiérrez Cía I, Moreno MA, Tirado Angles G, González Caballero M, Valero García R, Casa Venta J, García Mangas P, Mahave Carrasco R, Olmos Pérez F, Villabona Resano J, Williams L, Patiño Y, Margarit Ribas A, Flamarique Zaratiegui MT, Ortega RA, Sánchez Reinoso J, Diosdado Iraola Ferrer M, Mora Pérez Y, Carrazana Ososrio V, Prieto Fuentemayor JR, Díaz Águila H, Companioni Sola Y, Morales Valderas A, Solís Sotero M.

Author information

1
Intensive Care Unit, Hospital Can Misses, Ibiza, Spain. pazmerino@telefonica.net

Abstract

OBJECTIVE:

To estimate the incidence and characteristics of adverse events (AEs) and no-harm events (NHEs) in critically ill patients.

DESIGN:

Observational, prospective, 24-h cross-sectional study with self-reporting.

SETTING:

Seventy-nine intensive care units at 76 hospitals.

MEASUREMENTS:

Number of events, risk of AEs and NHEs, types of incidents, severity and avoidability of incidents.

RESULTS:

A total of 1017 patients were included in the study; 591 (58%) were affected by one or more incidents. Of the 1424 valid incidents, 943 (66%) were NHEs and 481 (34%) were AEs. The individual risk of suffering at least one incident was 62%, at least one NHE 45% and at least one AE 29%. The median number of incidents, NHEs and AEs was 6, 3 and 2 per 100 patient-hours, respectively. Seventy-four per cent of the incidents were related to medication (24%), equipment (15%), nursing care (14%), accidental withdrawal of vascular accesses and catheters (10%) or airways and mechanical ventilation (10%). AEs resulted in temporary damage in 29% and in permanent damage or damage that compromised patients' lives or contributed to their death in 4%. Incidents were avoidable in 79% of cases (90% in NHEs and 60% in AEs, P < 0.05).

CONCLUSIONS:

The individual risk for incidents in critical patients is high. Many incidents did not harm patients, some caused damage and a few were related to the patient's death. Most incidents were considered avoidable.

PMID:
22190588
DOI:
10.1093/intqhc/mzr083
[Indexed for MEDLINE]

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