Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

2010 ◽  
Vol 19 (2) ◽  
pp. 135-145 ◽  
Author(s):  
Hatem Ksouri ◽  
Per-Yann Balanant ◽  
Jean-Marc Tadié ◽  
Guillaume Heraud ◽  
Imad Abboud ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Quality Of Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Morbidity And Mortality ◽  
Care Practice ◽  
Unplanned Extubation ◽  
Morbidity And Mortality Conferences

Background Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units. Objectives To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety. Methods For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24–48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability. Results During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred. Conclusion In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.

Improving Quality of Care and Patient Safety Through Morbidity and Mortality Conferences

2014 ◽  
Vol 36 (1) ◽  
pp. 29-36 ◽  
Author(s):  
Gaëlle Bal ◽  
Elodie Sellier ◽  
Sandra D. Tchouda ◽  
Patrice François
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conferences

PP156 Risk Assessment Of Equipment Used In Intensive Care Units

2018 ◽  
Vol 34 (S1) ◽  
pp. 127-128
Author(s):  
Juang Horng Jyh ◽  
Loraine Martins Diamente ◽  
César Tadeu Spadella
Keyword(s):  
Adverse Event ◽  
Intensive Care ◽  
Quality Of Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Healthcare Professionals ◽  
Critical Patients ◽  
Process Failures ◽  
Hospital Equipment

Introduction:Knowledge and proper use of hospital equipment are essential for preventing adverse events associated with their use. The risks controls for medical devices and equipment are of major importance in ensuring patient safety and the quality of care delivered by healthcare professionals. Monitoring equipment (ME), infusion pumps (IP), and mechanical ventilators (MV) are frequently used in intensive care units, but they are subject to technical, human, and process failures that may pose harm to and even cause the death of patients. The aim of this study was to evaluate the risks related to the use of ME, IP, and MV in the adult intensive care unit (AICU) of a public hospital in Brazil, and to investigate the causes of technical complaints and the adverse events associated with them. We hope the outcomes may serve as a basis for the facility to create mechanisms to diminish the risk and increase the safety and quality of care delivered to critical patientsMethods:A 12-month prospective, observational descriptive study was conducted using an active and passive search of processes related to: hospital medical equipment use; available human and material resources; training programs and continuing professional education; equipment disinfection, sterilization, and assembly processes; and the hospital risk management measures regarding the reports and actions for technical, human, and process failures and the adverse events and incidents related to them. All the data collected were checked against current Brazilian legislation and the equipment technical manuals. The root cause of every failure and adverse event was investigated.Results:The active search identified seventy-five reports on technical complaints in the study period: sixty-five were related to IP, six to ME, and four to MV. The reasons for the complaints included: deficiencies in the quantity, qualification, training, and capacity of professionals handling the devices; inadequate disinfection of MV accessories; absence of or difficulty in accessing the equipment technical manuals; and a lack of preventive and corrective maintenance programs. One single adverse event caused by an IP medication error was attributed to a programing error.Conclusions:Failures and deficiencies in the knowledge and management of hospital equipment can potentially increase risks to patients and healthcare professionals. Increasing compliance with Brazil's current legislation related to the technical and operational norms of hospital equipment might create safer practices and improve care quality for critical patients.

scholarly journals Assessment of patient safety culture in intensive care units and factors affecting it

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M A Tlili ◽  
W Aouicha ◽  
H Lamine ◽  
E Taghouti ◽  
M B e n Dhiab ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Healthcare Quality ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Learning From Errors

Abstract Background The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors. Methods It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture. Results A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased. Conclusions This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients. Key messages The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

scholarly journals Avaliação do transporte crítico de pacientes: Uma revisão sistemática

2019 ◽  
Vol 19 (1) ◽  
pp. 615-647
Author(s):  
Leonardo Nogueira Melo ◽  
Vera Lúcia Freitas ◽  
Emanuel Pereira dos Santos ◽  
Raphael Dias de Mello Pereira ◽  
Vanessa Silva De Oliveira ◽  
...  
Keyword(s):  
Systematic Review ◽  
Quality Of Care ◽  
Adverse Events ◽  
Care Practice ◽  
Transportation Of Patients ◽  
Time Space ◽  
Revisión Sistemática ◽  
Trabajo En Equipo ◽  
Main Factors

Objetivo: Evaluar, según la literatura, cuáles son los principales factores considerados facilitadores y/o agravantes en la realización del transporte de pacientes en estado crítico.Método: Este estudio se trata de una revisión sistemática realizada con el método PICOResultado: Los periódicos seleccionados comprendían un espacio temporal en los últimos diez años, donde 6 periódicos fueron elegibles, basado en los criterios establecidos. Los resultados relatan que los temas encontrados en esta revisión demuestran una alineación entre la práctica asistencial y la literatura, pero para que el transporte sea realizado sin eventos adversos, es necesario que haya unión entre la gestión y los profesionales involucrados.Conclusión: Aunque los hallazgos demuestren una gran preocupación en relación a la calidad en la asistencia y en la preparación del equipo, los autores creen que más estudios deben ser fomentados una vez que el trabajo en equipo, a pesar de ser complejo, es la clave para la realización de los procedimientos con efectividad. Objective: To evaluate, according to the literature, the main factors considered facilitators and/or aggravating in the transportation of patients in critical condition.Method: This study is a systematic review performed using the PICO method.Results: The selected journals comprised a time space in the last 10 years, with six journals eligible, based on the established criteria. The results report that the themes found in this review demonstrate an alignment between care practice and literature, but, for a transportation without adverse events, there must be a union between the management and the professionals involved.Conclusion: Although the findings demonstrate a great concern regarding the quality of care and team preparation, the authors believe that more studies should be encouraged since teamwork, despite being complex, is the key to performing the procedures with effectiveness. Objetivo: Avaliar segundo a literatura quais são os principais fatores que são considerados facilitadores e/ou agravantes na realização do transporte de pacientes em estado crítico.Método: Este estudo trata-se de uma revisão sistemática realizada com método PICOResultado: Os periódicos selecionados compreendiam um espaço temporal nos últimos dez anos, onde 6 periódicos foram elegíveis, baseado nos critérios estabelecidos. Os resultados relatam que os temas encontrados nesta revisão demonstram um alinhamento entre a prática assistencial e a literatura, porém para que o transporte seja realizado sem eventos adversos, é necessário que haja união entre a gestão e os profissionais envolvidos.Conclusão: Embora os achados demonstrem uma grande preocupação em relação à qualidade na assistência e no preparo da equipe, os autores acreditam que mais estudos devem ser fomentados uma vez que o trabalho em equipe apesar de ser complexo, é a chave para a realização dos procedimentos com efetividade.

168 Impact of morbidity and mortality conferences on the incidence of adverse events in an intensive care unit (ICU)

2010 ◽  
Vol 19 (Suppl 1) ◽  
pp. A68-A69 ◽  
Author(s):  
B. Misset ◽  
C. Bruel ◽  
S. Touati ◽  
M. Dumain ◽  
M.-L. Moulard ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Adverse Events ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conferences

scholarly journals Effect of Evidence-Based Nursing Care Guidelines on the Quality of Care of Patients in Neurosurgical Intensive Care Units

2020 ◽  
Vol 24 (1) ◽  
pp. 56-67
Author(s):  
Zahra Tayebi Myaneh ◽  
◽  
Maryam Azadi ◽  
Seyedeh Zahra Hosseinigolafshani ◽  
Farnoosh Rashvand ◽  
...  
Keyword(s):  
Intensive Care ◽  
Quality Of Care ◽  
Intensive Care Units ◽  
Nursing Care ◽  
Evidence Based ◽  
Neurosurgical Intensive Care ◽  
Care Guidelines ◽  
The Mean ◽  
Evidence Based Nursing

Background: Evidence-based nursing care guidelines are important tools for increasing the quality of nurses’ clinical work. Objective: The aim of this study was to investigate the effect of implementing evidence-based nursing care guidelines on the quality of care of patients admitted to the Neurosurgical Intensive Care Units (NICUs). Methods: This is a quasi-experimental study on 54 nurses in NICUs of hospitals affiliated to Qazvin University of Medical Sciences selected using a convenience sampling technique and divided into two groups of intervention and control. The intervention included the teaching of evidence-based nursing guidelines and their implementation by the nurses. Before and two months after the intervention, the demographic characteristics and the quality of nurses’ patient care in both groups was evaluated by using a demographic form and a standard checklist with 37 items designed based on the standards of practice for All Registered Nurses (ANA). Data were analyzed in SPSS software using descriptive statistics (Mean±SD), and paired t-test, independent t-test and chi-square test. Findings: The mean score of nursing care quality in the two groups was not significantly different before intervention (P>0.05). After intervention, the mean score was 25.11±6.2 in the intervention group and 20.29±5.3 in the control group, and the difference was statistically significant (P<0.05). Conclusion: Implementation of evidence-based nursing care guidelines can improve the quality of nursing care. Therefore, it is recommended that the teaching of evidence-based nursing care guidelines should be on the agenda of the hospitals’ education unit and related departments.

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