Delayed Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures: A Root Cause Analysis of Unplanned ICU Admissions

• Published in: PloS one 2016-08, Vol.11 (8), p.e0161393-e0161393
• Main Authors: van Galen, Louise S, Struik, Patricia W, Driesen, Babiche E J M, Merten, Hanneke, Ludikhuize, Jeroen, van der Spoel, Johannes I, Kramer, Mark H H, Nanayakkara, Prabath W B
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Classification; Clinical outcomes; Computer and Information Sciences; Critical Illness; Delayed Diagnosis - psychology; Delayed Diagnosis - statistics & numerical data; Early warning systems; Failure analysis; Female; Health care; Hospital admission and discharge; Hospitalization - statistics & numerical data; Hospitals; Humans; Intensive care; Intensive Care Units - statistics & numerical data; Internal medicine; Male; Medical diagnosis; Medical Errors - psychology; Medical Errors - statistics & numerical data; Medical personnel; Medicine; Medicine and Health Sciences; Methods; Middle Aged; Monitoring; Monitoring, Physiologic - psychology; Monitoring, Physiologic - statistics & numerical data; Mortality; Nursing; Patient safety; Patients; People and Places; Physiologic monitoring; Physiology; Prevention; Research and Analysis Methods; Retrospective Studies; Root Cause Analysis; Studies; Systematic review
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0161393

An unplanned ICU admission of an inpatient is a serious adverse event (SAE). So far, no in depth-study has been performed to systematically analyse the root causes of unplanned ICU-admissions. The primary aim of this study was to identify the healthcare worker-, organisational-, technical,- disease- and patient- related causes that contribute to acute unplanned ICU admissions from general wards using a Root-Cause Analysis Tool called PRISMA-medical. Although a Track and Trigger System (MEWS) was introduced in our hospital a few years ago, it was implemented without a clear protocol. Therefore, the secondary aim was to assess the adherence to a Track and Trigger system to identify deterioration on general hospital wards in patients eventually transferred to the ICU. Retrospective observational study in 49 consecutive adult patients acutely admitted to the Intensive Care Unit from a general nursing ward. 1. PRISMA-analysis on root causes of unplanned ICU admissions 2. Assessment of protocol adherence to the early warning score system. Out of 49 cases, 156 root causes were identified. The most frequent root causes were healthcare worker related (46%), which were mainly failures in monitoring the patient. They were followed by disease-related (45%), patient-related causes (7, 5%), and organisational root causes (3%). In only 40% of the patients vital parameters were monitored as was instructed by the doctor. 477 vital parameter sets were found in the 48 hours before ICU admission, in only 1% a correct MEWS was explicitly documented in the record. This in-depth analysis demonstrates that almost half of the unplanned ICU admissions from the general ward had healthcare worker related root causes, mostly due to monitoring failures in clinically deteriorating patients. In order to reduce unplanned ICU admissions, improving the monitoring of patients is therefore warranted.