Patient Safety and Quality

Physician knowledge and skills and team communication improve safety in intensive care units

Communication errors contribute to the occurrence of adverse events (injury or harm due to care) in intensive care units (ICUs). Communication errors are common factors in medical mistakes; however, according to a study supported by the Agency for Healthcare Research and Quality (HS11902 and HS14246), morning briefings conducted with staff can improve ICU safety. A second study supported by AHRQ (HS11902) indicates that clinician knowledge and skills are more likely to reduce ICU incidents involving invasive lines, tubes, and drains than factors related to team communication. Both studies, conducted at the Johns Hopkins University School of Medicine, are summarized here.

Thompson, D., Holzmueller, C., Hunt, D., and others (2005, August). "A morning briefing: Setting the stage for a clinically and operationally good day." Journal on Quality and Patient Safety 31(8), pp. 476-479.

Researchers found that morning briefings with ICU staff can improve communication, which then improves patient safety in the ICU. The goal of the ICU morning briefing is to focus on clinical safety in real time and integrate the safety perspective into the daily ICU routine. The briefing includes the attending physician who directs ICU rounds (usually a specialist in intensive care), the clinical fellow (if applicable), and the night- and day-shift charge nurses.

The briefing is conducted before morning rounds, typically at 7:30 A.M. during the shift change from night to morning. Change of shift is a critical time for exchange of information between teams and often a time when information is missed or forgotten, which can result in adverse events or near misses. Three questions are answered during the briefing. First, what happened overnight that the team needs to be aware of, such as adverse events, near misses, and admissions and discharges? This discussion helps prioritize which patients should be seen first during rounds and highlights the need to investigate adverse events or near misses while the facts are still fresh. Second, where should morning rounds begin and how can information on new admissions, discharges, and work flow pressures be clarified? Caregivers address high-acuity patients first to provide immediate intervention and to set daily goals for optimum patient care. Next, they take care of patients ready for discharge to free up beds for new admissions. Third, what are the potential problems for the day, such as patient scheduling, equipment availability, outside patient testing, staffing, and provider skill mix? A staff member can be assigned to follow up on these concerns and inform the team about action taken.

Needham, D.M., Sinopoli, D.J., Thompson, D.A., and others (2005, August). "A system factors analysis of 'line, tube, and drain' incidents in the intensive care unit." Critical Care Medicine 33(8), pp. 1701-1707.

ICU patients often have feeding tubes, chest drainage tubes, and central venous catheters. The most common types of incidents in the ICU involve invasive line, tube, and drain (LTD) placement, maintenance, or removal. This study found that over 60 percent of LTD incidents are considered preventable and that they occur more often during holidays, among children, and among patients with medically complex conditions. Clinicians' knowledge and skills helped prevent LTD incidents while team communication was less likely to prevent them (probably because LTD procedures usually depend on a single individual).

The researchers used an anonymous Web-based ICU Safety Reporting System to report unsafe conditions and events in ICUs that could or did lead to patient harm. During a 12-month period, researchers identified LTD incidents at 18 ICUs in the United States. Of the 114 reported LTD incidents, over 60 percent were considered preventable. One patient death was attributed to an LTD incident. Of patients who suffered LTD incidents, 56 percent sustained physical injury and 23 percent had either an actual or anticipated longer hospital stay. LTD incidents were 3 to 4 times more likely to occur in the operating room, on a holiday, or in patients with medically complex conditions. They were nearly 8 times more likely to occur in patients aged 1 to 9 years than in older patients.

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