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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