Table 3 Sample free text description of near miss events in the ICU
From: An analysis of near misses identified by anesthesia providers in the intensive care unit
Description of incident | Causal mechanisms |
|---|---|
Patient from ICU with [right] radial [arterial] line. [Arterial] line tubing taped tightly around the thumb such that there was a groove in the skin. Patient intubated and unconscious so cannot tell if there is an injury to the digital nerve to thumb [that] may have been compressed for two days. | Poor culture of safety Failure to execute a task appropriately |
Patient with difficult mask and intubation extubated evening before major surgery and two teams caring for patient in ICU…did not communicate surgery schedule. | Poor culture of safety |
One of our pain service patients had a 3-hour delay between asking for oxycodone for breakthrough pain and when he actually got it…apparently the orders got missed in his transfer between the ICU and the floor. | Time pressure |
Hallway blocked on way to ICU - patient with high O2 requirements difficult to ventilate due to gurneys and carts blocking access for second provider to assist. Patient desaturated, [we] stopped and [the patient] recovered. | Faulty design Equipment malfunction |
Checking ICU equipment pre-emptively while on call: Glidescope [in first ICU] missing. Glidescope [in another ICU] with reusable handle plugged into end of disposable handle cord . . .so the cord had two handles on either side and no way to plug into the glidescope machine. Glidescope [in yet another ICU] without handles at all. | Equipment unavailability |