A system factors analysis of “line, tube, and drain” incidents in the intensive care unit*

Objective:To analyze the system factors related to “line, tube, and drain” (LTD) incidents in the intensive care unit (ICU). Design:Voluntary, anonymous Web-based patient safety reporting system. Setting:Eighteen ICUs in the United States. Patients:Incidents reported by ICU staff members during a 12-month period ending June 2003. Interventions:None. Measurements:Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported. Main Results:Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25–9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12–11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28–5.92), and age of 1–9 yrs (OR, 7.95; 95% CI, 3.29–19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11–0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09–2.97). Conclusions:Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events. LEARNING OBJECTIVESOn completion of this article, the reader should be able to: Describe risk factors for “line, tube, and drain (LTD) incidents.” Explain how to minimize these incidents. Use this information in the clinical setting. Dr. Pronovost has disclosed that he is the recipient of grant/research funding from the Agency for Healthcare Research and Quality and is a consultant for the Patient Safety Group, VHA. The remaining authors have disclosed that they have no financial relationships or interest in any commercial companies pertaining to this educational activity. Wolters Kluwer Health has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.

[1]  C. Holzmueller,et al.  A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS)* , 2004, Critical care medicine.

[2]  L. Andrews,et al.  An alternative strategy for studying adverse events in medical care , 1997, The Lancet.

[3]  S. Miyazawa,et al.  Analysis of human error in nursing care. , 1999, Accident; analysis and prevention.

[4]  R. Gibberd,et al.  Epidemiology of medical error , 2000, BMJ : British Medical Journal.

[5]  Peter J Pronovost,et al.  How can clinicians measure safety and quality in acute care? , 2004, The Lancet.

[6]  S. Tibby,et al.  Adverse events in a paediatric intensive care unit: relationship to workload, skill mix and staff supervision , 2004, Intensive Care Medicine.

[7]  T. Buckley,et al.  Critical incident reporting in the intensive care unit , 1997, Anaesthesia.

[8]  Jean-Blaise Wasserfallen,et al.  Human errors in a multidisciplinary intensive care unit: a 1-year prospective study , 2001, Intensive Care Medicine.

[9]  A. Chaturvedi,et al.  Catheter Malplacement During Central Venous Cannulation Through Arm Veins in Pediatric Patients , 1997, Journal of neurosurgical anesthesiology.

[10]  J. Tibballs,et al.  Complications of endotracheal intubation and mechanical ventilation in infants and children , 1992, Critical care medicine.

[11]  Albert W Wu,et al.  ICU incident reporting systems. , 2002, Journal of critical care.

[12]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[13]  P. Pronovost,et al.  Improving communication in the ICU using daily goals. , 2003, Journal of critical care.

[14]  T. Caeiro,et al.  [Error in medicine]. , 2004, Medicina.

[15]  J. J. Stambouly,et al.  Complications of care in a pediatric intensive care unit: A prospective study , 1996, Intensive Care Medicine.

[16]  C. Vincent,et al.  Framework for analysing risk and safety in clinical medicine. , 1998, BMJ.

[17]  Andrés Esteban,et al.  Accidental removal of endotracheal and nasogastric tubes and intravascular catheters , 2000, Critical care medicine.

[18]  B. Frey,et al.  Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach , 2000, Intensive Care Medicine.

[19]  Victoria J. Fraser,et al.  Reporting of medical errors: An intensive care unit experience , 2004, Critical care medicine.

[20]  R. Mcnutt,et al.  Why blame systems for unsafe care? , 2004, The Lancet.

[21]  J. Carthey,et al.  Pitfalls of adverse event reporting in paediatric cardiac intensive care , 2004, Archives of Disease in Childhood.

[22]  C. Wild.  Building a safer health system , 2001 .

[23]  J. Georgitis,et al.  Predictability and consequences of spontaneous extubation in a pediatric ICU , 1985, Critical care medicine.

[24]  Y. Donchin,et al.  A look into the nature and causes of human errors in the intensive care unit , 2022 .

[25]  P. Pronovost,et al.  Mechanical ventilation in Ontario, 1992–2000: Incidence, survival, and hospital bed utilization of noncardiac surgery adult patients* , 2004, Critical care medicine.