scholarly journals Problems Associated with Nursing Staff Shortage: An Analysis of the First 3600 Incident Reports Submitted to the Australian Incident Monitoring Study (AIMS-ICU)

1998 ◽  
Vol 26 (4) ◽  
pp. 396-400 ◽  
Author(s):  
U. Beckmann ◽  
I. Baldwin ◽  
M. Durie ◽  
A. Morrison ◽  
L. Shaw
Keyword(s):  
Nursing Staff ◽  
Contributing Factors ◽  
Staff Shortage ◽  
Patient Dependency ◽  
Monitoring Study ◽  
Minimal Data ◽  
Incident Reports ◽  
Set Up ◽  
Incident Monitoring

Although many studies have attempted to define appropriate nursing staff levels, allocation and patient dependency, minimal data is available on the effect of nursing staff shortage (NSS) on quality of care provided in intensive care. This study aimed to identify incidents associated with staff shortage as reported to the Australian Incident Monitoring Study-ICU (AIMS-ICU) project and to assess their estimated effect on patient outcome. A search of narrative keywords and contributing factors identified 89 nursing staff shortage incidents (NSS-INCIDENTS) and 373 incidents involving nursing staff shortage contributing factors (NSS-CF). NSS resulted from inappropriate rostering for current patient load (81%) and inability to respond to increased unit activity (19%). Most frequent associated incidents included problems with: drug administration/documentation (47), patient supervision (20), set-up of ventilators/ equipment (16), and accidental extubation (14). Undesirable patient outcomes included: major physiological change (22%), patient/relative dissatisfaction (12%), and physical injury (3%). This study suggests that inadequate staffing results in incidents and compromised patient safety.

scholarly journals The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An Analysis of the First Year of Reporting

1996 ◽  
Vol 24 (3) ◽  
pp. 320-329 ◽  
Author(s):  
U. Beckmann ◽  
I. Baldwin ◽  
G. K. Hart ◽  
W. B. Runciman ◽  
Keyword(s):  
Intensive Care ◽  
Safety Margin ◽  
National Study ◽  
First Year ◽  
Contributing Factors ◽  
Staff Members ◽  
Monitoring Study ◽  
Set Up ◽  
Incident Monitoring

The AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined “clinical situations”.

scholarly journals The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 520-528 ◽  
Author(s):  
R. K. Webb ◽  
M. Currie ◽  
C. A. Morgan ◽  
J. A. Williamson ◽  
P. Mackay ◽  
...  
Keyword(s):  
Patient Outcome ◽  
Human Error ◽  
Safety Margin ◽  
Monitoring Study ◽  
Set Up ◽  
Closed Claims ◽  
Voluntary Basis ◽  
Type Of Anaesthesia ◽  
Incident Monitoring

The Australian Patient Safety Foundation was formed in 1987; it was decided to set up and co-ordinate the Australian Incident Monitoring Study as a function of this Foundation; 90 hospitals and practices joined the study. Participating anaesthetists were invited to report, on an anonymous and voluntary basis, any unintended incident which reduced, or could have reduced, the safety margin for a patient. Any incident could be reported, not only those which were deemed “preventable” or were thought to involve human error. The Mark I AIMS form was developed which incorporated features and concepts from several other studies. All the incidents in this symposium were reported using this form, which contains general instructions to the reporter, key words and space for a narrative of the incident, structured sections for what happened (with subsections for circuitry incidents, circuitry involved, equipment involved, pharmacological incidents and airway incidents), why it happened (with subsections for factors contributing to the incident, factors minimising the incident and suggested corrective strategies), the type of anaesthesia and procedure, monitors in use, when and where the incident happened, the experience of the personnel involved, patient age and a classification of patient outcome. Enrolment, reporting and data-handling procedures are described. Data on patient outcome are presented; this is correlated with the stages at which the incident occurred and with the ASA status of the patients. The locations at which the incidents occurred and the types of procedures, the sets of incidents analysed in detail and a breakdown of the incidents due to drugs are also presented. The pattern and relative frequencies of the various categories of incidents are similar to those in “closed-claims” studies, suggesting that AIMS should provide information of relevance to those wishing to develop strategies to reduce the incidence and/or impact of incidents and accidents.

scholarly journals Oesophageal Intubation: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 608-610 ◽  
Author(s):  
R. Holland ◽  
R. K. Webb ◽  
W. B. Runciman
Keyword(s):  
Carbon Dioxide ◽  
Early Detection ◽  
Endotracheal Tube ◽  
Critical Incident ◽  
False Negative ◽  
The Other ◽  
Monitoring Study ◽  
Incident Reports ◽  
Oesophageal Intubation ◽  
Incident Monitoring

There were 35 oesophageal intubations in the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). These reports confirm existing impressions that misplacement of the endotracheal tube can occur in trained as well as untrained hands, and that auscultation is an unreliable test. On the other hand, the value of capnography is emphasised, with no false positives in the 16 cases in which the instrument was used. There was one false negative. Over the 4 years of the AIMS study, reports have declined in frequency. It is possible that the early detection of oesophageal intubation by capnography has altered its status to the extent that anaesthetists no longer regard it as a “critical” incident. It is highly recommended that the presence of the expected concentration of carbon dioxide in expired air be confirmed by capnography immediately after any endotracheal intubation.

scholarly journals Clinical Anaphylaxis: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 621-625 ◽  
Author(s):  
M. Currie ◽  
R. K. Webb ◽  
J. A. Williamson ◽  
W. J. Russell ◽  
P. Mackay
Keyword(s):  
Clinical Course ◽  
Management Strategies ◽  
Perioperative Period ◽  
Allergic Reactions ◽  
Monitoring Study ◽  
Incident Reports ◽  
Incident Monitoring

There were 57 reports of possible allergic reactions in the perioperative period in the first 2000 incidents reported to the Australian Incident Monitoring Study. These were examined and classified with respect to presentation, clinical course, agents implicated and management strategies employed. Reactions were graded as to probability of allergic aetiology and severity of systemic disturbance. Two deaths were reported. A method of determining an “allergy score” was devised as an indication of which reactions may be most deserving of further investigation.

scholarly journals Cardiac Arrest—An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 626-637 ◽  
Author(s):  
C. A. Morgan ◽  
R. K. Webb ◽  
J. Cockings ◽  
J. A. Williamson
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Fibrillation ◽  
Drug Administration ◽  
Vagal Stimulation ◽  
Cardiac Stimulation ◽  
Cardiac Compression ◽  
Monitoring Study ◽  
Incident Reports ◽  
Incident Monitoring

Eighty-seven cases of cardiac arrest from the first 2000 incidents reported to the Australian Incident Monitoring Study were reviewed. “Cardiac arrest” was taken to include patients who were either pulseless or had electrocardiographic asystole or ventricular fibrillation. Cases were grouped by primary cause—drug administration (19), vagal stimulation (16), hypoventilation (15), bleeding (13), anaphylaxis (6), direct cardiac stimulation (4) and miscellaneous (14). Overall, 20 patients died (23% of the 87 cases); all of these were in the hypoventilation, bleeding, or miscellaneous groups (4, 9 and 7 patients, respectively). Cardiac compression was performed in 66% of patients; 20% were defibrillated; adrenaline was given to 42% and bicarbonate to 3%. There was a clear anaesthetic cause for 46% of this series of arrests, and with hindsight, a preventable factor was present in over half (58%) of these. Preventative strategies regarding staffing, equipment, policy and procedures are suggested.

scholarly journals Physical Injuries and Environmental Safety in Anaesthesia: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 659-663 ◽  
Author(s):  
R. J. Singleton ◽  
G. L. Ludbrook ◽  
R. K. Webb ◽  
M. A. L. Fox
Keyword(s):  
Tooth Loss ◽  
Environmental Safety ◽  
Environmental Hazards ◽  
Operating Table ◽  
Needlestick Injuries ◽  
Physical Injuries ◽  
Monitoring Study ◽  
Eye Damage ◽  
Incident Reports ◽  
Incident Monitoring

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 56 (3%) involved environmental hazards or injuries to patients or staff. There were 17 cases of oral trauma (14 of tooth loss or damage, in 7 of which poor dentition played a role), 10 incidents involving problems with the operating table, 6 cases of skin or eye damage and 6 cases in which an electrical hazard was identified. Five incidents occurred during transport, and there were 4 cases of monitor induced trauma, 4 “needlestick” injuries and 4 miscellaneous incidents. Recommendations are made for trying to avoid or reduce the incidence of some of these problems.

scholarly journals Problems Related to the Endotracheal Tube: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 611-616 ◽  
Author(s):  
S. M. Szekely ◽  
R. K. Webb ◽  
J. A. Williamson ◽  
W. J. Russell
Keyword(s):  
Endotracheal Tube ◽  
Pulse Oximeter ◽  
Front Line ◽  
Endobronchial Intubation ◽  
Common Cause ◽  
Monitoring Study ◽  
Incident Reports ◽  
Oesophageal Intubation ◽  
Inappropriate Choice ◽  
Incident Monitoring

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to problems with the endotracheal tube; 189 (9%) were reported. The most common problem was endobronchial intubation which accounted for 42% of these 189 reports; endobronchial intubation was the most common cause of arterial desaturation in the 2000 incidents. Obstructions and oesophageal intubation each accounted for 18% of the 189 problems with tubes. The remainder was made up of disconnections and leaks (7% each), misplacements other than endobronchial or oesophageal (4%), inappropriate choice of tube (3%), cuff herniation (1%), failure to deflate the cuff and foreign body in the tube (0.5% each). The pulse oximeter and capnograph first detected 58% of these incidents; a further 25% were detected clinically. The pulse oximeter is the “front-line” monitor for endobronchial intubation, and the capnograph the “front-line” monitor for oesophageal intubation, disconnection and obstruction. Recommendations are made for how to prevent problems and how to determine the nature of those that do occur.

scholarly journals The ‘'Wrong Drug” Problem in Anaesthesia: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 596-601 ◽  
Author(s):  
M. Currie ◽  
P. Mackay ◽  
C. Morgan ◽  
W. B. Runciman ◽  
W. J. Russell ◽  
...  
Keyword(s):  
Drug Problem ◽  
Common Error ◽  
Common Drug ◽  
Drug Classes ◽  
Wrong Drug ◽  
Drug Storage ◽  
Monitoring Study ◽  
Similar Appearance ◽  
Incident Reports ◽  
Incident Monitoring

Amongst the first 2000 incidents reported to the Australian Incident Monitoring Study, there were 144 incidents in which the “wrong drug” was nearly or actually administered to a patient. Thirty-three percent of the incidents involved ampoules and just over 40% syringes; in over half of the latter the syringes were of the same size, and also, in over half, they were correctly labelled. In 81% of the 144 incidents the “wrong drug” was actually given. This was more common with syringes (93%) than ampoules (58%). Thus the most common error was actually giving the wrong drug from a correctly labelled syringe. The most common drug involved was a muscle relaxant in both ampoule and syringe incidents. In 74% of all reports, there was the potential for serious harm to the patient; however no deaths were reported. Factors which contributed significantly to the incidents were similar appearance, inattention and haste. “Failure of communication” was a significant factor in syringe incidents when two or more staff were involved. The only significant factor which minimised the outcome was rechecking of the syringe or drug ampoule before giving the drug. Strategies suggested to address the “wrong drug” problem include education of staff about the nature of the problem and the mechanisms involved; colour coding of selected drug classes for both ampoules and syringes; the use of standardised drug storage, layout and selection protocols; having a drawing up and labelling convention; and the use of checking protocols.

scholarly journals Patient Awareness during Anaesthesia: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 653-654 ◽  
Author(s):  
G. A. Osborne ◽  
R. K. Webb ◽  
W. B. Runciman
Keyword(s):  
Anaesthetic Agent ◽  
The Other ◽  
Patient Awareness ◽  
Patient Recall ◽  
Volatile Anaesthetic Agent ◽  
Low Concentrations ◽  
Monitoring Study ◽  
Incident Reports ◽  
Induction Of Anaesthesia ◽  
Incident Monitoring

Amongst the first 2000 incidents reported to the Australian Incident Monitoring Study there were 16 cases in which patient recall of perioperative events was consistent with awareness. Awareness that occurred in 3 of 10 cases during anaesthesia was attributed to low concentrations of volatile anaesthetic agent; the conduct of anaesthesia appeared to be unremarkable in the other 7. The remaining 6 cases involved the inadvertent paralysis of patients prior to induction of anaesthesia, most commonly by “syringe swap” when suxamethonium was given instead of fentanyl. Some of these patients were significantly distressed. These preliminary findings suggest that incident monitoring should be useful in the study of awareness associated with anaesthesia and the development of strategies to prevent it.

Sign in / Sign up

Export Citation Format

Share Document