| USA/2013 The application of intermittent pneumatic compression devices for thromboprophylaxis: an observational study found frequent errors in application of these mechanical devices in intensive care units. |
Observational/ Prospective. Total # of patients = 108 |
Observe the frequency of adverse events and describe the team’s adherence to the prescription of mechanical thromboprophylaxis using intermittent pneumatic compression devices |
Improper use of equipment |
- To seek new evidence on the use of mechanical thromboprophylaxis
- To raise awareness of the proper use of the compression device
- To study the consequences of errors |
| USA/2010 Discrepancies between medication orders and infusion pump programming in a pediatric intensive care unit |
Observational/ Prospective. Total # of beds = 30 |
Measure the discrepancies between medication orders for infusions and the medication being infused, evaluating the adjustments scheduled to the infusion pump in a pediatric intensive care unit |
Improper use of equipment |
- Coordination between health professionals and technology designers to provide intensive training in understanding how equipment works |
| France/2010 Adverse events with medical devices in anesthesia and intensive care unit patients recorded in the French safety database in 2005-2006 |
Quantitative/ Retrospective. Total # of notifications = 4,188 |
Define whether the quantity, seriousness, and causes of incidents with medical devices in anesthesia and critical care have changed over time (1998-2005) |
- Equipment failure
- Improper use of equipment |
- Educational improvement among health professionals regarding safe use of medical devices
- Elaboration of checklists
- Dissemination of didactic reports in journals |
| Brazil/2009 Transporte intra-hospitalar de pacientes sob ventilação invasiva: repercussões cardiorrespiratórias e eventos adversos
|
Observational/ Prospective, nonrandomized. Total # of transfers = 58 |
Check cardiorespiratory changes among patients transferred to diagnosis units or between sectors, and identify adverse events taking place during intra-hospital transfer |
- Team failure
- Equipment failure |
- Transfer made by skilled professionals, preferably specialized in intensive care
- Use of equipment to monitor vital signs and complications during transfer |
| Brazil/2009 Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva
|
Quantitative/ Crosssectoral. Total # of events = 550 |
Identify nursing care adverse events in an intensive care unit |
- Improper use of equipment
- Team failure |
- Survey of adverse events and analysis of causes
- Permanent education for nursing professionals |
| United Kingdom/2008 Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency |
Quantitative/ Retrospective. Total # of incidents = 12,084 |
Identify and classify incidents associated with equipment use |
- Equipment failure
- Improper use of equipment |
- Training the team to use new equipment
- Proper technical assistance and maintenance
- Check operational conditions before using the equipment
- Planning for situations of power surges and peaks |
| USA/2007 Programmable infusion pumps in intensive care units: an analysis of corresponding adverse drug events |
Quantitative/ Retrospective/ Documentary. Total # of patients = 4,604 |
Define the frequency of adverse events that could be prevented with intravenous medications in intensive care units to prevent errors when handling conventional and smart infusion pumps |
- Equipment failure
- Improper use of equipment |
- Regular evaluation of infusion pumps to find potential manufacturing or handling errors
- Raise awareness among the nursing team regarding the occurrence of devicerelated errors |
| Australia/2006 Adverse events experienced while transferring critically ill patients from the emergency department to the intensive care unit |
Observational / Prospective jointly with retrospective audit. Total # of transfers = 290 |
Define the incidence and nature of adverse events during emergency transfer to the intensive care unit in a tertiary reference hospital |
- Equipment failure |
- Regular review of conduct as strategic to prevent the occurrence of errors through verification of equipment and goals during transfer between sectors |
| Austria/2006 Patient safety in intensive care: results from the multinational Sentinel Events Evaluation study |
Observational/ Sectional. Total # of patients = 1,913 |
To access, at the multinational level, the prevalence and factors related to unintended events that compromise the safety of patients in intensive care units |
- Equipment failure
- Team failure |
- Implementation of protocols for prevention and early detection of errors Improve safety related to equipment maintenance |
| Brazil/2006 Ocorrências iatrogênicas em Unidade de Terapia Intensiva: análise dos fatores relacionados
|
Quantitative/ Prospective. Total # of incidents = 113 |
Identify structural factors in the intensive care unit and conditions of patients regarding iatrogenic occurrences, checking the association between seriousness of these occurrences and related factors |
- Equipment failure |
- Nurses’ education to prevent iatrogenic occurrences
- Structural improvements in the intensive care unit
- Monitoring of iatrogenic occurrences and studies about related factors |
| Australia/2004 Incidents relating to the intrahospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care |
Quantitative/ Sectional. Total # of notifications = 176 |
During intrahospital transfer of critically ill patients, identify incidents and establish the respective causes and contributing factors |
- Team failure
- Equipment failure
- Improper use of equipment |
- Provision of qualified labor force
- Continued monitoring of these events
- Permanent education to the team
- Adoption of protocols and checklists for intrahospital transfers. |
