Unplanned Removal of Medical Devices in Critical Care Units in North West England Between 2011 and 2016

Background The unplanned removal of medical devices poses a risk of harm to critically ill patients. Objective To determine rates, causes, and consequences of unplanned medical device removal, as well as factors mitigating harm to patients, in critical care units in the United Kingdom by reviewing patient safety incident reports. Methods Incidents of unplanned medical device removal in critical care units in North West England between 2011 and 2016 were retrospectively reviewed and classified. The incidents were classified by type of device displaced, staff and patient factors, causes and consequences of removal, and staff actions following removal. Displacement rates were calculated per 1000 patient days per unit. Results A total of 34 705 incident reports were reviewed, of which 1090 described unplanned device removal. The median rate of device removal was 0.7 (interquartile range, 0.4-2.2) per 1000 patient days per unit. Devices displaced most commonly included nasogastric tubes (317), central catheters (245), tracheostomy tubes (174), and endotracheal tubes (140). A total of 11 cardiac arrests were reported (8 associated with airway devices and 3 with central catheters). Factors contributing to displacement included initial placement (188), patient factors (563), and manual handling (238). Manual handling was cited in 49% of central catheter incidents and only 9% of nasogastric tube incidents. Patients’ organic confusion was a factor in 16% of endotracheal tube and 80% of nasogastric tube removals. Conclusions Unplanned device removal may cause patient harm and is often preventable. The causes and consequences depend on the type of device removed.