Skip to main content
SpringerLink
Log in

Fehler und Zwischenfälle in der Intensivmedizin

Eine Begriffs- und Standortbestimmung

Errors and incidents in intensive care medicine: definitions and status quo

  • LEITTHEMA
  • Published:
Intensivmedizin und Notfallmedizin

Abstract

Errors in medicine occur frequently and may subsequently lead to considerable morbidity, mortality, and economic consequences [1, 2]. Epidemiologic data from the USA report 44 000–98 000 deaths per year as a result of preventable medical and organizational errors and incidents. Besides others, the number of errors, incidents, and adverse events depends on the intensity of patient care, severity of illness, and the complexity of the particular organizational environment [3, 4]. Thus, intensive care medicine is among the most error-prone areas in every health care system. The following article is aimed to introduce the terminology and characterization of errors and incidents. Various methods for the assessment of errors and incidents are delineated. Frequent errors and incidents in intensive care medicine are discussed.

Zusammenfassung

Fehler sind in der Medizin häufig und die mit ihnen verbundene Morbidität, Letalität und ökonomischen Auswirkungen sind beträchtlich [1, 2]. Epidemiologische Daten aus den USA berichten von 44 000–98 000 Todesfällen jährlich infolge vermeidbarer medizinischer und organisatorischer Fehler und Zwischenfälle. Die Häufigkeit eines Fehlers, Zwischenfalls oder unerwünschten Ereignisses ist dabei, neben anderen Faktoren, abhängig von der Intensität der geleisteten Therapie und Pflege, dem Schweregrad der Erkrankung der Patienten und der Komplexität der organisatorischen Abläufe [3, 4]. Somit zählt die hochkomplexe Intensivmedizin zu einem der fehleranfälligsten Bereiche der stationären Krankenversorgung. Der folgende Beitrag führt vor allem in die Terminologie und Charakterisierung von Fehlern und Zwischenfällen ein. Darüber hinaus werden noch verschiedene Möglichkeiten der Fehlererfassung skizziert und häufig auftretende Fehler und Zwischenfälle in der Intensivmedizin sowie die zugrunde liegenden Ursachen dargestellt.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Literatur

  1. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA et al (1997) The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277(4):307–311

    Article  PubMed  CAS  Google Scholar 

  2. Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy Press, Washington, DC

    Google Scholar 

  3. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD (1995) The quality in Australian health care study. Med J Aust 163(9):458–471

    PubMed  CAS  Google Scholar 

  4. Bates DW, Miller EB, Cullen DJ, Burdick L, Williams L, Laird N et al (1999) Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group. Arch Intern Med 159(21):2553–2560

    Article  PubMed  CAS  Google Scholar 

  5. Weingart SN, Wilson RM, Gibberd RW, Harrison B (2000) Epidemiology of medical error. BMJ 320(7237):774–777

    Article  PubMed  CAS  Google Scholar 

  6. Graf J (2003) Do you know the frequency of errors in your ICU? Crit Care Med 31(4):1277–1278

    Article  PubMed  Google Scholar 

  7. Osmon S, Harris CB, Dunagan C, Prentice D, Fraser VJ, Kollef MH (2004) Reporting of medical errors: an intensive care unit experience. Crit Care Med 32(3):727–732

    Article  PubMed  Google Scholar 

  8. Graf J, von den Driesch A, Koch KC, Janssens U (2002) Identification and characterization of errors and incidents in a medical intensive care unit. Acta Anaesthesiol Scand 49:930–939

    Article  Google Scholar 

  9. Donchin Y, Seagull FJ (2002) The hostile environment of the intensive care unit. Curr Opin Crit Care 8(4):316–320

    Article  PubMed  Google Scholar 

  10. Reason J (2000) Human error: models and management. BMJ 320:768–770

    Article  PubMed  CAS  Google Scholar 

  11. Sexton JB, Thomas EJ, Helmreich RL (2000) Error, stress and teamwork in medicine and aviation: cross-sectional surveys. BMJ 320:745–749

    Article  PubMed  CAS  Google Scholar 

  12. Lawton R, Parker D (2002) Barriers to incident reporting in a health care system. Qual Saf Health Care 11:15–18

    Article  PubMed  CAS  Google Scholar 

  13. Reason J (2003) Human Error. Cambridge University Press, Cambridge

  14. Flanagan JC (1954) The critical incident technique. Psychol Bull 51:327–359

    Article  PubMed  CAS  Google Scholar 

  15. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AWet al (2003) Quality improvement in intensive care – evaluation of two methods: “facilitated” incident monitoring and retrospective medical chart review. Crit Care Med 31:1006–1011

    Article  PubMed  Google Scholar 

  16. Leape LL (1994) Error in medicine. JAMA 272(23):1851–1857

    Article  PubMed  CAS  Google Scholar 

  17. Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G et al (1993) Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med 21(1):40–51

    Article  PubMed  CAS  Google Scholar 

  18. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL et al (1995) A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 23(2):294–300

    Article  PubMed  CAS  Google Scholar 

  19. Walsh T, Beatty PCW (2002) Human factors error and patient monitoring. Physiol Meas 23:R111–R132

    Article  PubMed  CAS  Google Scholar 

  20. Alvarez GA, Cavanagh P (2004) The capacity of visual short-term memory is set by visual information load and by number of objects. Psychol Sci 15:106–111

    Article  PubMed  CAS  Google Scholar 

  21. Reason J (1990) The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci 327:475–484

    PubMed  CAS  Google Scholar 

  22. Helmreich RL (1991) Does CRM work? Air Line Pilot 60:17–20

    PubMed  CAS  Google Scholar 

  23. Thomas EJ, Sexton JB, Helmreich RL (2004) Translating teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation. Qual Saf Health Care 13(Suppl 1):i57–64

    Article  PubMed  Google Scholar 

  24. Leape LL, Berwick DM (2005) Five years after ‘To Err is Human’ – What have we learned. JAMA 293:2384–2390

    Article  PubMed  CAS  Google Scholar 

  25. Graf J (2006) Qualitätsmanagementund Leitlinien in der Intensivmedizin. Med Klinik 101(Sondernummer 1):115–118

    Google Scholar 

  26. Amoore J, Ingram P (2002) Quality improvement report: learning from adverse incidents involving medical devices. BMJ 325:272–275

    Article  PubMed  Google Scholar 

  27. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE et al (2004) Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32:2014–2020

    Article  PubMed  Google Scholar 

  28. Graf J (2003) Guidelines for critical care services and personnel – Innovations and improvements in patient care? Crit Care Med 31(11):2709–2710

    Article  PubMed  Google Scholar 

  29. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE et al (2001) Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 120(Suppl 6):375S–395S

    Article  PubMed  CAS  Google Scholar 

  30. Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH (2001) Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 161(10):1268–1279

    Article  PubMed  CAS  Google Scholar 

  31. Abramson NS, Wald KS, Grenvik AN, Robinson D, Snyder JV (1980) Adverse occurrences in intensive care units. JAMA 244(14):1582–1584

    Article  PubMed  CAS  Google Scholar 

  32. Oakley E, Stocker S, Staubli G, Young S (2006) Using video recording to identify management errors in pediatric trauma resuscitation. Pediatrics 117:658–664

    Article  PubMed  Google Scholar 

  33. Thomas EJ, Petersen LA (2003) Measuring errors and adverse events in health care. J Gen Intern Med 18:61–67

    Article  PubMed  Google Scholar 

  34. Beckmann U, West LF, Groombridge GJ, Baldwin I, Hart GK, Clayton DG et al (1996) The Australian incident monitoring study in intensive care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesth Intensive Care 24(3):314–319

    PubMed  CAS  Google Scholar 

  35. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamilton JD (1996) Quality in Australian health care study. Med J Aust 164(12):754

    PubMed  CAS  Google Scholar 

  36. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324(6):370–376

    Article  PubMed  CAS  Google Scholar 

  37. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA et al (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324(6):377–384

    Article  PubMed  CAS  Google Scholar 

  38. Frey B, Buettiker V, Hug MI, Waldvogel K, Gessler P, Ghelfi D et al (2002) Does critical incident reporting contribute to medication error prevention? Eur J Pediatr 161(11):594–599

    Article  PubMed  Google Scholar 

  39. Frey B, Kehrer B, Losa M, Braun H, Berweger L, Micallef J et al (2000) Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Med 26(1):69–74

    Article  PubMed  CAS  Google Scholar 

  40. Vincent C, Stanhope N, Crowley- Murphy M (1999) Reasons for not reporting adverse incidents. J Eval Clin Pract 5:13–21

    Article  PubMed  CAS  Google Scholar 

  41. Leape L (2001) Moving beyond a punitive mind-set. Interview by Patrick Mullen. Manag Care 10(7):45–54

    PubMed  CAS  Google Scholar 

  42. Wright D, Mackenzie SJ, Buchan I, Cairns CS, Price LE (1991) Critical incidents in the intensive therapy unit. Lancet 338(8768):676–678

    Article  PubMed  CAS  Google Scholar 

  43. Buckley TA, Short TG, Rowbottom YM, Oh TE (1997) Critical incident reporting in the intensive care unit. Anaesthesia 52(5):403–409

    Article  PubMed  CAS  Google Scholar 

  44. Hart GK, Baldwin I, Gutteridge G, Ford J (1994) Adverse incident reporting in intensive care. Anaesth Intensive Care 22(5):556–561

    PubMed  CAS  Google Scholar 

  45. Bracco D, Favre JB, Bissonnette B, Wasserfallen JB, Revelly JP, Ravussin P et al (2001) Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 27(1):137–145

    Article  PubMed  CAS  Google Scholar 

  46. Flaatten H, Hevroy O (1999) Errors in the intensive care unit (ICU). Experiences with an anonymous registration. Acta Anaesthesiol Scand 43(6):614–617

    Article  PubMed  CAS  Google Scholar 

  47. Reader T, Flin R, Lauche K, Cuthbertson BH (2006) Non-technical skills in the intensive care unit. Br J Anaesth 96:551–559

    Article  PubMed  CAS  Google Scholar 

  48. Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P et al (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation study. Intensive Care Med 32:1592–1598

    Article  Google Scholar 

  49. Barach P, Small SD (2000) Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 320:759–763

    Article  PubMed  CAS  Google Scholar 

  50. Zimmerman JE, Wagner DP, Draper EA, Knaus WA (1994) Improving intensive care unit discharge decisions: supplementing physician judgment with predictions of next day risk for life support. Crit Care Med 22(9):1373–1384

    Article  PubMed  CAS  Google Scholar 

  51. Leape LL, Berwick DM, Bates DW (2002) What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 288(4):501–507

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstr. 1, 35033, Marburg, Germany

    J. Graf &  M. Max

  2. Innere Medizin, St.-Antonius-Hospital, Dechant-Deckers-Str. 8, 52449, Eschweiler, Germany

    U. Janssens

Authors
  1. J. Graf
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. U. Janssens
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Max
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Graf.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Graf, J., Janssens, U. & Max, M. Fehler und Zwischenfälle in der Intensivmedizin. Intensivmed 44, 119–128 (2007). https://doi.org/10.1007/s00390-007-0754-1

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00390-007-0754-1

Key words

Schlüsselwörter

Search

Navigation