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Critical Incidents in the ICU - Coggle Diagram
Critical Incidents in the ICU
What
unexpected
unintended
undisired
Associated with actual/potential harm
Never events
Definition
Serious incidents
preventable
safety recommendations should have been implemented
Types
Surgical
Wrong site
Wrong implant
Retined foreign object
Medical
Mis-selection fo strong pottasium
Wrong route medication
Insulin overdose
General
Falls from windows
Entrapment in beds
Scalding
ICU
Transfusion of ABO incompatible blood
Misplaced NG tube
Mis-selection fo high dose midazolam
Prevention
two person checking
"barcodes
Checklists eg WHO
Mandatory elearning
Medication
Error
Prescription
Transcription
Preparation
Dispensing
Adverse drug events
5.1 to 87.5 per 1000
Prevention
Situational
Avoid excessive hours
Minimise interuptions
Supervision
Process
Computerised
Standardisation
Oversight
Staffing levels
Pharmacist
Education
Quality assurnace
Why
ICU is invasive
Frequent medications
lack capcity/autonomy
Low physiological reserve
Sedation
Management
Patient safety
Inform responsible clinican
Inform patient/family - full disclosure
Incident report
Strategic Executive Information system
Root cause analysis