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J Crit Care. 2018 Oct;47:238-244. doi: 10.1016/j.jcrc.2018.07.012. Epub 2018 Jul 17.

Safety incidents in airway and mechanical ventilation in Spanish ICUs: The IVeMVA study.

Author information

1
Department of Intensive Care Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain. Electronic address: a.alonso@salud.madrid.org.
2
Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay.
3
Department of Intensive Care Medicine, Hospital Universitario de Torrejón, Madrid, Spain.
4
Department of Intensive Care Medicine, Hospital Universitario del Henares, Coslada, Madrid, Spain.
5
Department of Intensive Care Medicine, Hospital Can Misses, Ibiza, Spain.
6
Department of Intensive Care Medicine, Hospital Universitario La Paz-Carlos III, IdiPAZ, CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
7
Department of Intensive Care Medicine, Hospital Clínico, Zaragoza, Spain.
8
Department of Intensive Care Medicine, Hospital Universitario Joan XXIII, Tarragona, Spain.

Abstract

PURPOSE:

To assess incidence, related factors and characteristics of safety incidents associated with the whole process of airway management and mechanical ventilation (MV) in Spanish ICUs.

MATERIALS AND METHODS:

Observational, prospective, 7 days cross-sectional multicenter study. Airway and MV related incidents were reported using structured questionnaire. Type, characteristics, severity, avoidability and contributing factors of the incidents were assessed.

RESULTS:

Participant ICUs: 104. Inclusion of 1267 patients; 745 (59%) suffered one or more incidents. Incidents reported: 2492 (59% non-harm-events, 41% adverse events). Individual risk of suffering at least one incident: 66.6%. Incidence ratio (median) of incidents: 2 per 100 patient-hours. 73.7% of incidents were related to MV process, 9.5% to tracheostomy, 6.2% to non-invasive MV, 5.4% to weaning/extubation, 4.4% to intubation and 0.8% to prone position. Temporary damage was produced in 12% incidents, while 0.8% was related to permanent injuries, risk to the patient's life or contributed to death. Incidents were considered avoidable in 73.5% of cases. 98% of all incidents had 1 or more contributing factors.

CONCLUSIONS:

MV is a risk process in critical patients. Although most incidents did not harm patients, some caused damage and a few were related to the patient's death or permanent damage. Preventability is high.

KEYWORDS:

Adverse events; Incident reporting and analysis; Intensive care unit; Mechanical ventilation; Patient safety

PMID:
30056219
DOI:
10.1016/j.jcrc.2018.07.012
[Indexed for MEDLINE]

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