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Article
October 3, 1980

Adverse Occurrences in Intensive Care Units

Author Affiliations

From the Division of Critical Care Medicine, Presbyterian-University Hospital, University Health Center of Pittsburgh (Drs Abramson, Wald, Grenvik, and Snyder); the Resuscitation Research Center (Dr Abramson); and the School of Law (Dr Robinson), University of Pittsburgh, Pittsburgh.

JAMA. 1980;244(14):1582-1584. doi:10.1001/jama.1980.03310140040027
Abstract

Analysis of 145 reports of adverse occurrences involving patients in a medical-surgical intensive care unit (ICU), during the years 1974 through 1978, disclosed 92 instances of human error and 53 cases of equipment malfunction. A peak occurrence of reported incidents was found between midnight and 1 am. Harm occurred more frequently if the patient was unattended (72%) than attended (49%) during the incident. Mortality for patients with an incident report filed during their ICU admission (41%) was higher than for all ICU patients (21%). The importance of a well-structured incident-reporting program to minimize problems of human error and device malfunction is stressed.

(JAMA 244:1582-1584, 1980)

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